I learned about Bounce-Backs back in my Emergency Medicine days. A bounce-back is a patient who you saw in the ER and discharged but then returned within 48 hours with the same complaint. A lot of time is spent in emergency medicine education talking about how to handle bounce-backs. The basic message is “Beware! You may have missed an important diagnosis the first time!”
Bounce-backs happen in correctional medicine, too. Bounce-backs can happen in jails, where we often deal with patients we do not know well. But bounce-backs also happen in prisons, when patients we do know well have a new complaint. Just like in emergency medicine, a bounce-back in a jail or a prison is a patient who comes to the medical clinic with a new complaint, receives a diagnosis and treatment and then re-kites for the same complaint within a couple of days. Here are a couple of examples.
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.
The final major difference between correctional medicine and medicine in the outside world is this: Our patients do not go home. We have a captive audience. Literally! Believe it or not, this is a very important medical point.
Back in my previous life as an ER doc, if I asked a patient to come back tomorrow to be rechecked, I knew that few of them would. It was just too much hassle. They had to find a ride back to the ER (especially hard for the homeless or those without cars), they had to endure another prolonged wait in the ER waiting room. And they would be charged big bucks for another ER visit! No wonder so few of my scheduled follow-ups actually returned!
Once I began to practice in a jail clinic, I soon realized that the situation is much different. The patient I see in clinic today will not go home. She will go to her housing dorm down the hall. I know exactly where she will be tomorrow–or in a week. If I want to see her again tomorrow, I can. In fact, I can reliably see her in follow up anytime I want to.
One might think, “So what? What difference can it possibly make on the practice of medicine that our patients do not go home?” The answer is that this fact does indeed have several important consequences for the practice of clinical medicine. I can think of at least four.Continue reading →
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 →
It used to be that “Bath Salts” were, well, salts that you would use in a bath. Not anymore! Nowadays, “Bath Salts” refers to a designer drug of abuse that is marketed like traditional bath salts to give legitimacy to the transaction. They are also marketed as computer screen cleaners, jewelry cleaners and bug spray. They are, of course, not intended to be used for any of these purposes; they contain synthetic designer drugs used to get high. Continue reading →
So let’s say you order a lab test on a patient. Or an X-ray. Or let’s say you order old records. When the results are returned to you, how do you document this? What I have often seen is the practitioner documenting by initialing and dating the hard copy, as has been done on the lab order in the picture. I see this commonly.
But this is poor medical practice. Notice on the lab report that there is a critical lab abnormality. Did the practitioner who initialed the lab report see this? What does it mean? What is he going to do about it? Initials and date tell you nothing, other than the practitioner actually held the lab slip. Continue reading →
One thing that has long bugged me about how medicine is practiced in the United States is that medical professionals for the most part have no idea how much stuff costs. Doctors prescribe medications that their patients cannot afford to buy—even when cheaper alternatives are available. We order tests not knowing what the patient is going to be charged.
This phenomenon occurs nowhere else in American culture. It is kind of odd when you think about it. It would be like going to the grocery store and having no prices on any of the food. You could only get the meat that the butcher recommended, but he wouldn’t know the price of anything, either. The first inkling you would have about costs would be when you got your bill in the mail a month later: “Wow—that chuck roast was $200.00 a pound!” Continue reading →