When Covid-19 burst onto the scene three months ago, the jail administrators and the medical teams in my jails initiated several common sense practices to reduce the possibility of Covid infiltrating the jails. These included screening and quarantining new inmates before allowing them into the dorms, screening jail employees daily, doing lots of Covid tests and, perhaps most importantly, having deputies wear masks at work. The good news is that, so far, there have been no cases of Covid-19 in any of my jails (knock on wood here).
However, there seems to be growing evidence of “Covid
Fatigue” in my community. When I go out
in public, I am one of the very few still wearing a mask. And this is unfortunately spilling over to
the correctional facilities. I did a
clinic at one of my smaller jails this week and was surprised and dismayed to
see that the deputies were no longer wearing masks. In the meantime, Community Covid cases are
climbing, so the risk of transmitting Covid to the jail is actually greater
than it was, say, a month ago.
I recently published the official position paper of the American College of Correctional Physicians (ACCP) on the treatment of Hepatitis C in incarcerated patients (found here). However, some state legislatures (and others who which authorize funds for inmate medical care), have been reluctant to fully fund Hepatitis C treatment. Because of this, ACCP has formally approved the following Position Paper to encourage full funding of HepC treatment among incarcerated inmates.
“We’ve got another one,” My nurse told me on the phone. “He
says he was exposed to Covid.”
Ever since Covid-19 came to my town, many people being
arrested have begun to say that they have Covid or have been exposed; the
thought being that “If I have Covid, they can’t put me in jail.” Of course, it doesn’t work that way. They go to jail anyway.
Unless you’ve been living under a rock, you have been hearing about the threat of a Corona virus pandemic. Every day, the evening news anchor breathlessly gives an update of the number of new cases, the number of new countries affected and the number of new deaths. You probably already know that this disease was originally found in China. What you may not know (but you should if you work in corrections) is that Chinese prisons were especially hard hit. This disease spreads most rapidly where people are enclosed together, like nursing homes, cruise ships and prisons. If this disease gets a foothold in the United States, correctional institutions are likely to suffer.
One of the consequences of the heroin epidemic we all are experiencing is a marked increase in the number of skin abscesses presenting to the jail medical clinics. Jails have always had to deal with skin abscesses. In fact, the single most popular JailMedicine post has been the Photographic Tutorial on Abscess I&D (found here). But since the heroin epidemic, the number of skin abscess we see has exploded. It is not unusual nowadays to lance an abscess every day!
The reason for this big increase in skin infections, of course, is that heroin users tend to share needles to shoot up, and these dirty needles leave behind the bugs that cause abscesses. And since shooting up causes the abscesses, they tend to be found where addicts commonly shoot up–like the inner elbow, the forearm and even overlying the jugular veins of the neck.
Fortunately, just in time for this onslaught of abscesses, my good friend Neelie Berlin PA taught me a new method of lancing simple abscesses that is quicker and easier—yet just as effective—as the method I had been using for my entire career. I’m going to call this new method of draining abscesses “The Berlin Method.”
Who says you can’t teach an old Doc new tricks? I have wholeheartedly gone over to the Berlin procedure. It is THE method I use now to drain simple abscesses.
Today’s JailMedicine post is a pictographic tutorial on how to do this new easier method of lancing simple abscesses.Continue reading →
One of the greatest concepts I have run across since I finished school is the Number Needed to Treat (abbreviated NNT). NNT was never taught back when I went to medical school (we had barely given up The Four Humors!). Instead, we were taught “the p-value.” Does anyone else remember the p-value? The p-value of a study, it turns out, is a relatively poor measure of study validity, partly because it implies an “all-or-nothing” kind of understanding of studies: either the study is “valid” (meaning a p-value of >95%) or it is not. Either the treatment being studied works or it does not. And if a treatment works, it must work for all people.
Of course, in real life, this is not the case. No drug is universally good or bad. All drugs help some people, harm some people (with adverse side effects) and make no difference one way or another in some people. These numbers can be derived from any study’s data. There is even a fabulous website devoted to this where you can look up the NNT and its corollary, the Number Needed to Harm (NNH) for all sorts of drugs and treatments (found here).
Since it is influenza season and time for us to get our flu shots (I got mine yesterday), I thought it would be a great time to see how beneficial the flu vaccine is. What is the NNT for the flu vaccine? And while we are at it, why don’t we also look at the data on oseltamivir (Tamiflu) while we’re at it?
As you probably know, Sovaldi (sofosbuvir) is an important new treatment for Hepatitis C infection that was released this last December and has been aggressively marketed by its maker, Gilead, ever since. The problem is that Gilead is charging an unheard of, jaw-dropping, $1,000.00 per pill for Sovaldi. This translates into a MINIMUM of $84,000.00 for Sovaldi alone for the simplest course of Hep C treatment. Add on the other necessary drugs and take into consideration more complicated cases, and a single course of therapy for Hepatitis C will cost between $100,000.00 and $250,000.00.
This price has placed prison systems in a no-win situation–and not just prisons, but also Medicaid, insurance companies, and HMOs. On one hand, Sovaldi is a good drug that, in fact, represents a significant advance in Hepatitis C treatment. Lots of Hepatitis C patients could potentially benefit from Sovaldi. On the other hand, no one can afford Sovaldi. Treating every potential Hep C patient using Sovaldi would bankrupt everyone. There is no good way out of this dilemma. Continue reading →
It is worthwhile to check drug prices now and then (once a quarter seems about right) to see what is happening in the pharmaceutical world. When you do this, you will find some drugs that have inexplicably shot up in price. One recent example was doxycycline, which went from around ten cents a tablet to over two dollars a tablet in a couple of months.
On the other hand, drugs that we think of as expensive in the back of our minds sometimes are no longer expensive. Olanzapine (Zyprexa) is now cheaper than haloperidol. Risperidone is cheaper still.
And sometimes, a drug that is a bit more expensive than its alternative is still the most cost-effective treatment based on “the hassle factor,” meaning frequency of dosing, ease of administration, potential for diversion–that sort of thing. Drugs prescribed for outbreaks of genital herpes are like that, in my opinion. Valacyclovir can be more cost-effective than acyclovir for the treatment of recurrent genital herpes.Continue reading →
I ran across a couple of interesting articles about antibiotics recently.
In the first article, entitled We Will Soon Be in a Post-Antibiotic Era, CDC researchers predict that the end of the antibiotic era is coming quickly. Antibiotic resistance is developing so rapidly now, that it is only a matter of time until antibiotics just don’t work anymore. This actually is not surprising when you think about it. If we kill all of the microbes that can be killed by our antibiotics, then of course the only ones left will be those that cannot be killed by antibiotics, in other words, that are resistant. The fact that this will happen eventually is a no-brainer.Continue reading →
Over the weekend, my family and I went to see the “Mummies” exhibition at the local museum. One display invited participants to feel squares of leather that were said to feel like mummy skin. As I watched the family of six ahead of me all caress the leather, I wondered how many hundreds of people had fondled this exhibit. I wondered if it ever was cleaned. I wondered how many viruses were lurking there. It reminded me that the world is a dirty place. I remembered that one of my professors in medical school had referred to the dirtiness of the world as “The Fecal Veneer.”
The theory of the Fecal Veneer states that the whole world is covered with a thin layer of, well, shit (Sorry! I will use that crude term only once). When I say ‘the whole world,” I mean every place and every surface, including floors, chairs, desk tops, clothes . . and even swimming pools, according to this report! In some places, the fecal veneer is thick—like the gas station public restroom I was in recently that must have last been cleaned when it was built. In other places, the fecal veneer is quite thin, like in a hospital surgical suite. But it is still there! Most places are someplace in between. How thick the fecal veneer is depends on how often it is cleaned.
The theory of the Fecal Veneer is scientifically demonstrable! All you have to do is to wipe down any surface and plate the residue onto agar. You will inevitably grow fecal bacteria, like E. coli. Even the wall of the surgical suite will grow an occasional E. coli. Since the Fecal Veneer does not just include feces, but any and all human secretions, you can also find viruses, MRSA and all sorts of other nasty things.
People interact with their environment and hence with the Fecal Veneer mainly with their hands. That is how we transfer the Fecal Veneer to our own persons. In other words, like every other surface, we people are covered with a fecal veneer–but it is thickest on our hands. Our hands are the vectors that transfer the fecal veneer from place to place.
Many diseases, of course, are transmitted from person to person via the Fecal Veneer. Sick people excrete the virus infecting them into one or another of their secretions. They deposit these secretions on their hands, which in turn deposit the infectious secretions on something they touch, like a doorknob. Someone else touches the doorknob, gets the infected goobers on their hands and then transfers the virus into their mouths, say, when they eat.
Yes, some diseases like TB are transmitted by aerosolized droplets . . . but this is uncommon. The flu and the common cold, for example, are mostly transmitted via the fecal veneer. I guess they can be transmitted via the air—but not in the same way as TB, where the micro-droplets can float in the air for a long time and for long distances. Instead, if influenza is transmitted through the air, it occurs like this: an infected person coughs or sneezes and launches a mucous goober through the air. This arcs across the room and lands directly in someone’s face or into their food. This can and does occur (which is why you should cough and sneeze into your elbow), but it is more likely that the mucous bomb will land on some surface, like a desk top. However, even more likely than this aerial bombardment would be that the ill person coughs or sneezes infected mucous onto his hands, which touch something (like a doorknob), which you then touch with your hand, and those dirty hands then transfer the virus to your mouth when you eat.
The bottom line here is that hands contaminated by the Fecal Veneer are the source of many common illnesses. Think back to the last time you got sick with a bad cold or the flu. That is likely how you got it—via dirty hands
The solution, of course, is to wash our hands a lot. We tend to underestimate how contaminated our hands get by contacting the items around us. By cleaning our hands, we accomplish two ends—we make it less likely that we ourselves will become infected by pathogens in the Fecal Veneer and we also will be less likely to transmit pathogens to others.
Of course, it is possible to go overboard and wash our hands too often. I was taught to wash my hands after each and every contact with a patient—up to 40-50 times a day sometimes. This much washing can cause skin breakdown in the form of rashes and cracked skin that I used to get especially on my knuckles. The problem is that bacteria counts on damaged skin actually go up. The solution is to use hand sanitizers in addition to washing.
What if you wear gloves? They keep your hands free of contamination, don’t they? Well, not entirely. Here is a study that showed that significant hand contamination occurred 13% of the time despite surgical gloves. Gloves help, but sometimes the Fecal Veneer can creep even through surgical gloves.
I suspect that most of us remember to clean our hands often when we are working around patients. However, often, we forget the presence and danger of the Fecal Veneer in the wide world. And we often mistake where the greatest danger of contamination lies. Remember that dirty public bathroom I spoke of earlier? As bad as it was, that bathroom was probably not the greatest threat I faced that day, partly because I recognized that it was dirty. In the news recently was a report that said that Women’s Handbags May Contain More Germs Than the Average Toilet Flush .
It is clear that the more insidious dangers to our cleanliness are those surfaces that we do not recognize as being really, really “fecal veneered.” So, along those lines, here is an extra-credit quiz for you:
What is the dirtiest surface that people touch all of the time without cleaning their hands afterward (including you, probably)?
Hint: this surface is handled by hundreds, maybe thousands, of people and usually is never cleaned. Answer: Continue reading →