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.Continue reading
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.Continue reading
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.”Continue reading
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.Continue reading
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.Continue reading
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.Continue reading
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.Continue reading
I have found that many correctional practitioners, especially in jails, do not understand the license requirements of the federal Drug Enforcement Agency (DEA) and, as a result, do not have all of the DEA licenses that they are legally obligated to obtain.
Take, for example, a correctional physician that we will call Dr. K who is employed full time a a large urban jail and has had a DEA license for that jail for many years. On the side, she also provides medical services to three other smaller jails, where she does clinics once a week. The question is whether her one DEA license covers her activities at the other jails. Dr. K has always thought that she only needs one DEA license—just like she only needs one Driver’s License—and it will cover all of her activities.
But the real answer is, “No,” Dr. K is not in compliance with DEA regulations.Continue reading
Today’s post is a repost of an article I wrote previously about Constipation. Concurrent with this article, I have added a Sample Guideline on Constipation to the Guideline Section of JailMedicine (found here).
I have decided after many years of dealing with complaints of constipation both in the ER and in correctional facilities that bowel health is the last taboo subject. We all received “The Talk” (about sex and reproductive health) when we were adolescents. But nobody seems to talk about how to have a proper bowel movement. It is a subject that inevitably causes giggling and uncomfortable laughter. It is not spoken of in polite society. As a result, many people do not understand how their bowels work. I have found this to be a big problem in the jails I work in. Inmates complain of constipation when they are not really constipated. They are bowel-fixated when there is no reason for them to be. Often, they need education more than they need laxatives. To this end, I want to discuss several essential factors relating to understanding and treating constipation that may help make your correctional medicine practice a little easier.Continue reading
My last post about MAT in jails generated a lot of excellent responses–so many, in fact, that I realized that my discussion of MAT in jails was incomplete. I would like to enlarge the discussion about the proper role of MAT in jails by responding to these comments. Before I do, I want to make sure that we are all looking at the issue from the same perspective. Please consider how MAT should be used in three different jails.READ MORE