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:
Local anesthetic. I generally use 1% lidocaine with epinephrine.
5cc syringe with 18 g and 25-27 g needles
Silicone vessel loops (we stock 2 sizes)
Noyes alligator forceps
Island gauze dressing
This technique does not require sterile technique or prepration. It is a clean technique, not a sterile one.
The abscess is palpated and the edge of the abscess is identified in two spots 180° opposite each other.
You can use a pen to draw on X at your marked spot.
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.
A wheal of local anesthetic is raised at those two spots
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
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.
The teeth of the Noyes passer are then used to grab the silastic vessel loop and that is pulled back through the abscess cavity.
The silastic vessel loop is then tied in a loose air knot with usually 6 to 8 throws of knots on top.
The tails of the vessel loop are then cut leaving a very loose suture with the silastic vessel loop in the skin.
An island dressing is applied over the top of this and the patient is free to go.
The patient may shower and generally the only dressing necessary for this technique is an island dressing every day for the next few days.
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.
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.
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.
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.
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.
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.
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!
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 →