What Do These Five Patients Have In Common?

What do these five patients have in common (Fill in the Blank).

As you arrive to work at a jail medical clinic, you are told about five different jail patients. Each of the five carries a totally different diagnosis, but all have one thing in common.

Patient one is a 52 year old man booked into the jail four days ago for a DUI. He seemed all right for the first two or three days, but now, you are told, he has not eaten anything for 24 hours and last night he ____________________.

Patient two is a 24 year old woman who was arrested yesterday for refusing to leave a grocery store as it was closing. Since her arrival at the jail, you are told, she has been talking non-stop in a very loud voice and last night she _____________ .

Patient three is a 19 year old man who was arrested for drug possession. The deputies have not been able to book him because he also has been talking loudly and nonstop, although, unlike patient number two, his speech is largely non-sensical. But like patient number two, last night he also ________________.

Patient four is a 28 year old homeless man who was arrested two days ago for taking his clothes off in the library. He is cooperative mostly but spends most of his time talking about being spied on by the FBI through the jail loudspeaker. He thinks any food prepared by the jail is poisoned so will only eat pre-packaged commissary items. Last night, he _______________ .

The last patient is a 76 year old man who has been incarcerated in the jail for over six months. He has never caused any trouble in all of that time until last night, when he was incontinent, resisted any efforts to change his clothes, and threatened the deputies. Oh, and also he __________________________.

I’m sure that you have figured out how to fill in the blanks with what these five very different patients have in common. They all did not sleep last night.

Patient number one is going through alcohol withdrawal. If he is disoriented and having “different place” hallucinations plus severe tachycardia, he already has Delirium Tremens and needs to go to the hospital. However, some withdrawal patients will become sleepless before they become delirious and so may be able to be successfully treated at the jail. Either way, the treatment for this patient is benzodiazepines and rehydration. You’ll know you have given him enough Valium or Ativan when he sleeps.

Patient number two is manic. Depending on how cooperative she is and the capabilities of the jail, she also may need urgent evaluation by a psychiatrist. Typical maintenance therapy for her would be a mood stabilizer like Lithium or divalproex. However, an acutely manic patient who is not sleeping may first benefit from an antipsychotic and and a benzodiazepine. First and foremost, she needs to slow down enough to sleep.

Patient number three is high on methamphetamine. The “antidote” to meth toxicity is benzodiazepines. Once he gets enough benzos on board to counteract the meth effects, he will sleep. Whether this takes place at the jail or the hospital depends, again, on how sick he is and the capabilities of the jail.

Patient number four is acutely psychotic. He should receive antipsychotics and, at least initially, benzodiazepines. Since he is paranoid, he may be resistant to taking these voluntarily. A psychiatric consult and court order may be needed to treat him and get him to sleep.

Patient number five is acutely delirious. There can be many causes for this, but in this particular case, the patient is septic from a urinary tract infection. He will need to go to the hospital, where treatment will include antibiotics and benzodiazepines to help him to sleep.

Lessons

I have often heard jail practitioners say something like “We don’t treat insomnia in our facility.” This is, of course, incorrect. All of these sleepless patients, for example, must be treated and one important guide to the success of the treatment is that each patient goes to sleep. Of course you will treat sleeplessness when medically appropriate to do so!

You might argue that these patients are not really insomniacs; insomnia implies wanting to sleep but being unable to do so. None of these patients complain about not sleeping. In my opinion, this semantic argument misses the point. Our patients need to sleep. We will treat those who are truly not sleeping, from whatever cause. Sleepless is almost always an important symptom pointing to a more serious underlying medical condition.

Since none of these patients will fill out a kite complaining of not sleeping, we medical practitioners have to rely on our deputies and correctional officers to alert us about about patients who are not sleeping. This underscores the importance of training our non-medical coworkers (who are often our eyes and ears) on what conditions and behaviors should be referred to medical.

Personally, even though I get a lot of calls when I am on-call, the problem is that I am not called enough rather than that I get called too much. One reason for this is that correctional officers sometimes have had bad experiences in the past from a cranky practitioner. We need to remember that deputies and correctional officers do not have our medical training and so are going to worry about things that maybe we wouldn’t.

Even if nine calls out of ten are perhaps unnecessary, that tenth call is critically important! Always thank the officer for calling, be kind and follow up.

As always, what I have written here is my opinion, based on my expereince, training and research. I could be wrong!

Please share an experience you have had in your facility with a sleepless patient in comments!

What Does “Medically Necessary” Mean?

Let’s say one of my jail patients has a moderate-sized inguinal hernia.  I want to schedule surgery to have the hernia fixed, but to do so, I have to get authorization.  This is not unusual.  Just like the outside, before I can do medical procedures or order non-formulary drugs, I must get the approval of the entity that will pay the bill.  By contract, my jails house inmates from a variety of jurisdictions, such as the Federal Marshals, ICE, the State Department of Corrections and other counties.  This process of “Utilization Management” is very similar to getting pre-authorization from an insurance company or Medicaid in the free world, probably because Corrections simply copied the outside pre-authorization process.

Having done this process hundreds of times over the years, both in the free world and in Correctional Medicine, I am struck by a phrase that keeps coming up: “medically necessary.”  When authorization for a procedure is denied, the reason often given is that it is “not medically necessary.”  I then have to argue that what I am requesting is, indeed, medically necessary.  The problem is that there are many possible definitions of “medically necessary,” and I believe many disagreements arise because two parties understand “medical necessity” differently.

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What is the most common mistake made when treating withdrawal?

What is the most common mistake made when treating withdrawal in a correctional facility?

Consider these two patients:

  • A jail patient booked yesterday is referred to medical because of a history of drinking.  He has a mild hand tremor and “the look” of a heavy drinker. But he says he feels fine and has no complaints. His blood pressure is 158/96 and his heart rate is 94.
  • A newly booked jail patient says that she is going to go through heroin withdrawal.  She is nauseated but still eating and has no gooseflesh or rhinorrhea.  Her heart rate mildly elevated.

In many jails, neither of these patients would be started on treatment for withdrawal at their first visit to medical.  But this would be a mistake!  Both patients should be started on treatment for withdrawal immediately.

The most common mistake made when treating withdrawal in a jail is not to treat the withdrawal at all!

Both of these patients have the potential to slide downhill rapidly.  And in both cases, the potential benefits of starting treatment far, far outweigh any potential liability.

Let’s look at these cases in more detail.

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You Need a Plan for Corona virus in your Facility

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. 

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The Rules for Treating Benzodiazepine Withdrawal

Patients are dying in correctional facilities from benzodiazepine withdrawal!  This is not just a theoretical observation; this really is happening. This fact bothers me since benzo withdrawal deaths are preventable.  Benzodiazepine withdrawal is easy to treat!  It is certainly easier to treat benzo withdrawal than the other two potentially deadly withdrawal states, alcohol and opioids.   By far, the most common cause of benzodiazepine deaths is, of course, not treating it!    

So, is your facility at risk to have a patient die of benzodiazepine withdrawal?  To find out, compare your policies to the following Rules for the Treatment of Benzodiazepine Withdrawal.             

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How Can You Violate the Hippocratic Oath by Providing Medical Care to the Needy?

Five months ago, the Journal of the American Medical Association (JAMA) published an editorial entitled “Can Physicians Work in US Immigration Detention Facilities While Upholding Their Hippocratic Oath?”  (Spiegel, Kass and Rubenstein, JAMA online August 30, 2019). This article generated a lot of interest and comment in the lay press. As just one example, NBC News wrote “Medical care for detained migrants violates doctors’ oath, says physician in JAMA commentary.”

Who’s going to provide medical care for these people?
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Gabapentin for Musculoskeletal Pain?

At one of my recent jail medical clinics, three patients in a row requested prescriptions for gabapentin.  One was a patient newly arrived from the Idaho Department of Corrections to be housed at my jail due to prison overcrowding.  He had already been prescribed gabapentin at the prison for complaints of low back pain radiating to one leg and wanted me to continue it–forever.  The second patient was prescribed gabapentin by his outside practitioner for a boxer’s fracture that had been surgically repaired years ago.  The third was prescribed gabapentin at a previous jail due to “nerve damage” from an old gunshot wound to the upper arm (he had a large scar but no functional disability or decreased sensation).

Gabapentin prescriptions for nonspecific musculoskeletal pain have clearly become common in the community and in corrections.  These three patients represent only a fraction of the similar cases I see in my jails! I suspect that this gabapentin-mania is being driven by a belief that gabapentin is preferable to prescribing narcotics (though I would not think any of the three patients above would be candidates for narcotics).  Gabapentin, in fact, is often prescribed for musculoskeletal pain in my community first line—before NSAIDS and Tylenol, even—and many, like these three patients, subsequently believe that gabapentin is something they will need to take for the rest of their lives. 

The problem is that prescribing gabapentin for musculoskeletal pain is not evidence-based and (in my opinion) bad medicine.

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Oral Testing of Reported Penicillin Allergies?

Penicillin is miraculous.  It was discovered in 1928 by Alexander Fleming (founding the modern era of antibiotic medicine) and is still the most common antibiotic prescribed in my jails.  The dentist and I use Penicillin VK as our preferred initial agent for dental infections.  I prescribe PCN VK, as well, for strep throats.  I use amoxicillin occasionally for sinus infections and UTIs and even amoxicillin/clavulanate (Augmentin) occasionally.

Because penicillin is so useful (and inexpensive), I hate to hear the words “I’m allergic to penicillin.” If a patient with a dental infection can’t take penicillin, for example, the dentist commonly prescribes clindamycin, which is expensive, a pain to administer three times a day and has potentially bad side effects.  I have seen more than one patient who developed C. difficile after getting a broad-spectrum antibiotic because of a reported penicillin allergy–probably unnecessarily!

This problem is pretty common since about 10% of the adult population will report a penicillin allergy.  However, research has shown that, when tested, more than 90-95% of patients who state that they have a penicillin allergy really do not. These patients can be harmed by giving them an inferior antibiotic more likely to cause them harm than plain old penicillin.

The test most commonly used to gauge true allergic status is Penicillin Skin Testing (PST). No jail or prison that I know of does skin prick tests.  We also don’t refer patients reporting penicillin allergy to an allergist for testing.  We just groan and prescribe an inferior antibiotic.

However, this could potentially change based on research published this year on the safety and efficacy of “Direct Challenge” penicillin allergy testing.  Direct challenge means giving a low-risk (this is important) patient an oral dose of whatever penicillin you want to prescribe and observing them for an hour for an allergic reaction. This has been done in studies and has been reported to be safe and effective.

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Prescribing Without an Exam?

The State Board of Medicine in my home state recently sent out a bulletin about the practice of “friendly prescribing” to people who the practitioner has not examined.  For example, a friend might call me and say something like “I have a sore throat.  Will you call me in a prescription for antibiotics?”  I’m sure that almost everyone who has practiced medicine has received such phone calls!  The Board of Medicine was concerned about this. They went so far as to to condemn as unethical the practice of issuing such prescriptions without ever examining the patient or documenting the encounter.

In my opinion, this applies to correctional physicians prescribing to new inmates they have never seen, as well.

Examining a patient through the phone.
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When Should Medical Clearance Be Done? PLUS Sample Guideline!

When arresting officers arrive with their charges at a certain large urban jail, the first person they see when they come through the doors is a nurse. The nurse quickly evaluates the arrested person to determine whether a medical clearance is needed before the person can be booked. If a clearance is needed, the arresting officer has to transport the prisoner to a local ER and then return with the medical clearance in hand.

One evening (so the story goes), an arresting officer arrives at the jail bodily dragging a prisoner through the pre-book door by the backseat of his pants and coat. “This guy’s an a**hole,” the officer says. “He won’t do anything I ask. He just ignores me.” He then dumps the prisoner on the floor. The nurse kneels down by the prisoner briefly, looks up and says, “That’s because he’s dead!”

Medical clearances are a hugely important and often neglected part of the jail medical process.

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