Comfort Items: Why Not?

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.

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Why Correctional Medicine is often Driven by Lawsuits

Imagine, if you will, a nurse who is assigned to take care of 50 patients on a medical floor—by herself. Clearly, this is an impossible task.  There are just too many patients for one nurse to adequately monitor.  But this nurse gamely does her best.  Now let’s say that there is a bad outcome and an investigation.  Even if the understaffing problem is recognized, it would be easy—and tempting–to scapegoat the nurse, especially if there was no intention of fixing the staffing problem (“We can’t afford to hire more nurses!”)  Instead, the scapegoated nurse would be replaced by a new nurse, who, once again, would be expected to care for 50 patients.

Such were my thoughts when I read this article about the problems with the medical care for inmates in the Illinois prison system (found here):  https://www.chicagotribune.com/news/local/breaking/ct-met-illinois-prison-health-lawsuit-20190103-story.html. The article says that there have been so many problems with medical care in the Illinois prison system that a class action lawsuit has successfully forced Illinois to make sweeping changes to the prison medical system.  What is not mentioned in the article is that similar lawsuits have happened before in other states and will happen again. 

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Transforming Our Approach to Chronic Pain

One of the most fearful and frustrating events in my correctional medicine world used to be when a new chronic pain patient would arrive in my clinic.  A typical patient would be a “Ralph,” a middle-aged man who has had chronic back pain for many years.  Ralph has had a couple of back surgeries, steroid injections and more than one kind of stimulator, none of which has been effective.  He arrived at the jail taking a long list of sedating medications such as muscle relaxers, gabapentin, and sleeping aids plus, of course, big opioids.  In addition, Ralph has alcohol abuse issues.  The reason he is in jail is a felony DUI charge.  Now he is in my medical clinic, looking expectantly at me.  How am I going to fix his pain problem? 

The answer, of course, is that I am not.  I am not that smart.  He has already seen lots of doctors, including pain specialists and surgeons, who have tried almost everything that can be tried and they have not fixed his chronic pain problem.  I’m not going to be able to, either.  In my opinion, the most common and serious mistake made in the treatment of chronic pain in corrections is when we imply that we can eliminate chronic pain. 

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Can the Oakland Raiders Be Saved Using the Principles of Medical Research?

One of my good friends is a die-hard Oakland Raiders fan.  Those of you who follow pro football know that Oakland has fallen on hard times recently.  They went from being one of the best teams in the league two years ago to one of the worst teams in 2018 with a dismal 4-12 record.  As a result, my friend has had to suffer taunts from fans of better teams—like me!  He has become despondent.

But it doesn’t have to be this way!  The Raiders can quickly and easily turn their season around by using the tried-and-true techniques of medical research.  If a pharmaceutical company did 16 clinical trials of their new potential blockbuster, Drug X, they would never let a 4-12 outcome get them down.  When published, I guarantee those trial results would look a lot better than 4-12.  The Oakland Raiders can use the same techniques to improve their own season record.

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Guest Post–How I Assess Weight Loss in Correctional Facilities

Today’s Post was written by Todd Wilcox, MD.  Todd is the Medical Director of the Salt Lake County Jail in Salt Lake, Utah. He is a past president of the American College of Correctional Physicians and a frequent–and excellent–lecturer.  This article was originally published in CorrDocs, the journal of the ACCP.

Weight loss is a common complaint among our patients and the evaluation of this problem takes up a lot of clinical and administrative time. In many instances, the weight loss complaints are unfounded and the patients are not medically compromised by their weight loss. However, there are a lot of situations where the weight loss is indeed medically concerning and sorting out the two groups presents some challenges. Continue reading

Is a Concrete Cell Really the Best We Have To Offer Our Mentally Ill?

Consider the case of a 60-year-old patient I will call “Library Man.” While at the public library, Library Man took off most of his clothes and was talking loudly to no one in particular. The police were called, of course. He was charged with disturbing the peace and brought to my jail.

Jails basically have three types of housing areas. First are dormitory-style rooms with 60-100 residents. Library Man cannot be housed there—the young aggressive inmates would prey on him. Second are smaller cells that hold two to four inmates. The problem with these cells is that even if the jail could guarantee gentle cell mates, it would be hard to monitor Library Man in such cells. Such cells tend to be in out-of-the-way places and have small windows on the doors. The only place that Library Man can be reasonably housed in most jails is “Special Housing,” which refers in this case to a single-man isolation cell with lots of plexiglass to allow easy observation. Such rooms are designed to have nothing that someone could use to harm themselves, so they are made entirely of concrete and steel—even the bed. This is where Library man ends up—basically in a large concrete box.

Unfortunately, this is not a good place for Library Man to be. You may have guessed that Library Man is a homeless schizophrenic who had gone off of his meds. He is harmless–certainly not a danger to himself or to others. In his psychotic state, he does not understand why he was arrested and jailed. Library Man would benefit from familiar surroundings and normal social interaction with people. He will get neither of these in the alien and sterile environment of his concrete isolation cell. Continue reading

How Did I End Up in Jail? from MedPage Today

I have begun a new blog that is being published on MedPage Today entitled “Doing Time:  Healthcare Behind Bars.” The difference between that blog and JailMedicine is the audience.  JailMedicine is written for medical professionals already working in a jail or prison (bless us all!). The MedPage Today blog is written for medical professionals who have no idea what Correctional Medicine is all about.  The first post of Doing Time follows: Continue reading

Reader Question: How Safe Is Correctional Medicine?

Ryan writes:

Hi Dr. Keller. I am a third year Physician Assistant student at the Rochester Institute of Technology. I am beginning to write a research paper, for which I have chosen to write about Correctional Medicine. Your blog appears to be an excellent resource, especially because there are so few publications on Jail Medicine. I was wondering if you or any of your colleagues would be willing to answer a few questions for my paper. If so, please contact me (contact information below), I would really appreciate it!

tcb-37079_resized1_325286Ryan’s questionnaire and contact information appears at the end of this blog post if anyone would like to help him with this very worthwhile project. If Ryan gives me permission, I will publish his paper here on JailMedicine!

It would take too long for me to answer all of Ryan’s questions here, but I would like to answer a couple of his questions that I found interesting. They are:

• What special training was required of you prior to starting the job? Self-defense?
• What are the security measures like while working?
• Are you accompanied by guards? Do you possess weapons? Are assaults common?

Ryan, there are several common misconceptions about medicine practiced in jails and prisons. One of these is that jails and prisons are dangerous places to work; that assaults by inmates on medical staff are common. Actually, this is not true.

In fact, I personally have found that my jail medical clinics are a much safer work environment than where I worked before. I started out as an Emergency Physician and worked in a busy ER for upwards of 25 years. During that time, I have been slapped, punched and kicked–several times! I was spat upon. I was peed upon. I was pooped upon (don’t ask).  I wrestled with out-of-control patients. I was threatened with violence many times. Though this never happened to me, one of my colleagues had a patient pull a knife on her in a small ER exam room. We found many guns in ER patient’s clothing. Guns were even found hidden in our ER waiting room! I’ve seen no shootings in my ERs, but gunfire in ERs elsewhere in the country are not uncommon. ER doctors and ER staff have been killed.

But none of these have ever happened to me in  the 15 years that I have been working in Correctional Medicine. My jail medical clinics have been much safer overall than emergency departments. The danger of assaults and violence are way less. There are several reasons for this.

1. Weapons are forbidden in correctional facilities. The Detention Deputies and Correctional Officers do not carry guns while on duty. Guns, and knives and other such weapons are not allowed in correctional facilities.
2. Inmates in jail and prison are, for the most part, sober when I see them. The most dangerous patients in the ER were those who were drunk or high. Inmates coming to scheduled “Sick-call” clinics are not.
3. Detention deputies are always nearby. We try to safeguard inmate privacy, but Safety and Security take precedence over privacy. This means that security staff are always nearby. In most clinical encounters, the detention deputy is just outside the room or down the hall, so that there is some privacy, but if something happens, the deputies can be there in an instant. In other cases, if an inmate has a high security level deputies may literally stand right by me. Especially dangerous inmates may even be shackled when I examine them.
4. Inmates are punished for acting badly in clinic. This punishment can take the shape of loss of privileges (like not being able to buy from the jail commissary or even the loss of visitation rights), transfer to maximum security status or even additional criminal charges.
5. I even can control profane language better in the jail than I could in the ER. In the jail, I can terminate a clinic visit if an inmate swears at me, knowing that I can see him again tomorrow. In the ER, I had to put up with bad language much more often because that visit was likely my one-and-only chance to make the diagnosis. If I sent the patient away, I probably would not see them again.

This does not mean that inmate on staff violence is non-existent; because it does happen. Detention deputies are assaulted by inmates. Medical personnel, on the other hand, are much, much safer than your typical Emergency Room.

How safe do you feel in your facility? Please comment!

Please Respond to Ryan’s Questionaire:

• What attracted you to working in Correctional Medicine?
-Did you have prior healthcare experience that influenced your decision?

• Could you tell me about the correctional facility you work at?
-Name, location, patient population, security level, For-profit or Public health organization, etc.

• What is your relationship like with the inmates?
-What approaches do you use to gain and maintain their respect?

• What special training was required of you prior to starting the job?
-Self-defense? Legal? Psychosocial?

• What is your daily schedule like?

• What are the security measures like while working?
-Are you accompanied by guards? Do you possess weapons? Are assaults common?

• How difficult is it to balance optimizing your patient outcomes and maintaining a good patient-provider relationship with the security guidelines of the facility?
-Ex: What happens if a patient needs services beyond what your facility can provide?
-How do you handle patients concealing personal information to you that is potentially dangerous to other inmates or out of line with the facilities rules?

• Do you have problems with patient compliance?
-Do patients administer their own pills? If not, how do you ensure compliance?
-Are special dietary requirements able to be accommodated? Are patients able to get enough exercise?
-How do you promote continuity of care upon inmate release?
-How much of your job is teaching your patients and other staff members?

• What are some of the more common or interesting presenting problems?

• Are you multilingual? Do you have interpreters at your facility?

• Do you find it hard to maintain professional objectivity while working with certain criminals?
-If you have treated patients facing execution, what has that dynamic been like?

• Do you have students rotate through your facility?
-If so what are some of the unique opportunities that a correctional medicine rotation offers?

• What has been the greatest thing you have learned from your job?

Please send responses to Ryan at RJP4380@RIT.edu

Inappropriate Drugs in Jails and Prisons–Continued!

Matt, Correctional Pharmacist. Everyone Needs One!

In my last post on this subject (found here), I mentioned three medications that I think should rarely, if ever, be allowed in correctional institutions.  I would like to expand this list today.

In my personal protocol on this subject, I break problem medications into four categories, depending on three criteria:

1.  The risk of abuse the medication has in a correctional setting.

2. How much potential benefit the medication has.

3.  Whether there is ready availability of other, less problematic, substitute medications. Continue reading