Correctional Medicine is Different: We Can’t Fire Our Patients—and They Can’t Fire Us!

Posted on October 7, 2016 by Jeffrey Keller MD

This post is the third in a series exploring how Correctional Medicine is different than medicine practiced outside of jails and prisons. The previous two differences were The Principle of Fairness and All Clinical Encounters are Discussed Back in the Dorms.

There is a controversy in pediatrics that I have been following recently. Some pediatricians have been dismissing children from their practice if their parents will not allow them to be vaccinated. This practice has been criticized as punishing innocent children for the actions of their parents but the pediatricians defend it by saying they are just trying to protect their other patients from being exposed to pertussis, measles and other transmittable diseases in the waiting room.

This story illustrates an extreme example of something that we all know: that the practice of “firing” patients is commonplace in outside medicine. Many of my jail patients have been dismissed from medical practices, some more than once! Patients can be fired for variety of offenses. Some violate the contracts of their pain clinics. Some are dismissed for simply not following the doctor’s advice—like to get their children vaccinated. Many are no longer welcome when they cannot pay their bills or have lost insurance coverage. (One orthopedist that I know routinely sends a dismissal letter to his patients on their 65th birthday since he refuses to participate in Medicare). Finally, patients can be fired for just being too difficult to deal with. One jail patient in particular I remember screamed drunkenly at his doctor’s secretary to the point that she called the police. He received his official dismissal letter while he was in jail.

Well! Things are different in Correctional Medicine! We can’t fire our patients. Our patients remain our patients no matter what. It doesn’t matter if they violate the terms of a pain contract by, say, diverting medications. It doesn’t matter if they refuse to follow our advice. It doesn’t matter if they are difficult to deal with. Continue reading →

Do Uncomplicated Lacerations Need To Be Closed Within Six Hours?

Posted on June 26, 2016 by Jeffrey Keller MD

Dr. Keller,
What do you think of the rule for lacerations that says a laceration has to be sutured within six hours or it cannot be sutured at all? At our facility, we send lots of inmates to the ER for simple cuts because the PA isn’t scheduled to be at the facility until the next day. If a cut is 10 hours old, why can’t it be fixed? Where did this rule come from?
Kim A.

Thanks for the question, Kim. The short answer to this question is that that this belief is a myth. Uncomplicated lacerations can, indeed, wait more than 6 hours to be repaired.

“There is a common misconception that all wounds must be either sutured within a few hours or left open and relegated to slow healing and an unsightly scar.” Roberts and Hedges’ Clinical Procedures in Emergency Medicine

Continue reading →

The M-Word–Malingering

Posted on May 22, 2016 by Jeffrey Keller MD

I went to the always excellent NCCHC spring convention in Nashville last month. One of the many outstanding presentations was done by frequent lecturer Deana Johnson. Deana talked about the risks of using the word “malingering.” Her basic message was to be very careful about saying that an inmate is malingering—in fact, perhaps we should never use that word.

I was surprised by the degree of spirited disagreement from several members of the audience. They pointed out that “malingering” has a specific medical meaning and sometimes—even often—it is an appropriate medical diagnosis. They pointed out that malingering is listed as an official diagnosis in DSM-5 and that outside medical agencies, like mental hospitals, use the term malingering. If we can’t say that an inmate who is clearly faking is malingering, what are we supposed to say?

Today in Jail Medicine, I am going to tackle the term malingering. It turns out that there is indeed a correct and proper way to use the term malingering in correctional medical practice—but it is tricky and most often (in my experience) done incorrectly, with resultant bad consequences.

There are three important reasons for this. First, most people have an inaccurate idea of what malingering actually means in a medical sense and so use the term inaccurately. Second, the use of the term “malingering” also carries with it an emotional definition that MUST be taken into account when it is used in a medical document. Finally, use of the term “malingering” has important consequences for patient relations, patient behavior and time management.

The bottom line, in my opinion, is that “malingering” is a term that should very rarely be used in correctional medicine. There are better and more precise ways to convey medical information. But if you do absolutely want to use the term “malingering,” you need to know how to use the term correctly. Continue reading →

An Introduction to Correctional Medicine–A Guest Post by Bruce Boynton, MD

Posted on March 5, 2016 by Jeffrey Keller MD

Today’s JailMedicine post was written by Bruce Boynton, MD. Dr. Boynton has been a Regional Medical Director of the prisons in New Mexico and currently is the Statewide Medical Director in Mississippi. He wrote this article to help introduce newly hired practitioners to the world of Correctional Medicine. I think it is excellent!

MD: Hi, I’m Doctor Jones and I’ve just started working here at Riverbend. I’ll be holding my first sick call this afternoon and I understand you’re the officer assigned to the clinic.

CO: It’s good to meet you Doc; welcome to Riverbend.

MD: There is something I’d like to ask you. I have a lot of experience in Family Practice but I’m new to corrections. Is there anything special you think I need to know? I suppose that people are people and medicine is medicine no matter where you go. Isn’t that right?

CO: Well Doc, people are people, but Riverbend ain’t the Mayo Clinic. Continue reading →

Taming the Beast—Gabapentin. Ban It or Regulate It?

Posted on February 7, 2016 by Jeffrey Keller MD

In my last post, I began with a question from Christy. Her facility was considering banning gabapentin from their facility due to rampant abuse and diversion problems. My last post dealt with gabapentin’s interesting history and the evidence base for off-label gabapentin prescribing. This JailMedicine post will deal with the pros and cons of banning gabapentin versus creating rules to regulate gabapentin use and hopefully minimize diversion and abuse. Continue reading →

Proton Pump Inhibitors: Dependency and Risk

Posted on November 3, 2015 by Jeffrey Keller MD

I recently saw yet another patient come into the jail who was worried about one particular drug in a long list of medications he was taking—his Nexium. “I can’t miss a day of taking Nexium” he said, “It has to be refilled right away!” He was more concerned about Nexium than his blood pressure meds, his diabetes medications or his mental health medications. There was a lot of Nexium-anxiety on display.

And the funny thing is, this happens all the time! I have seen lots of jail patients wedded to their proton pump inhibitor, whether Nexium, Prilosec, Protonix or what ever. A prescription of a PPI often becomes a lifelong need.

I think it is important for all prescribers to understand why this is so. And why, despite this, it is not a good idea for most people to be on PPIs for long periods of time. Prescribers tend to under-estimate both the potential harms of long-term PPI use and the potential for patients to become dependent on them.

To this end, today’s Jail Medicine post presents two “Must Know” papers about Proton Pump Inhibitors. Continue reading →

How Does Jail Medicine Differ From Prison Medicine?

Posted on May 11, 2015 by Jeffrey Keller MD

I was talking to a physician colleague of mine the other day and he was quite interested in what I was doing and in correctional medicine in general. Like most people (it seems), he had no idea what the difference was between jails and prisons and what the practice of medicine is like in the two settings. While the term “Correctional Medicine” encompasses medicine practiced in both jails and prisons, the actual practice of medicine in the two settings can be as different as that of an emergency department and a nursing home.

A good way to illustrate the difference between jails and prisons and between jail medicine and prison medicine is by using patients as models. To this end, let’s consider the cases of two patients entering the correctional system for the first time, a homeless alcoholic and a successful middle aged business man who sees his primary care physician regularly. Continue reading →

Book Review: Correctional Health Care Patient Safety Handbook

Posted on April 10, 2015 by Jeffrey Keller MD

If you’ve ever gone looking for books, articles, or–well anything! written about correctional medicine, you will quickly notice that there really isn’t very much out there. The specialty of correctional medicine is in its infancy. You can count the number of published books about the subject on less than two hands.

So a day in which a new book about correctional medicine is published is always a good day. And if by chance that book also happens to be well written and truly useful, well, that’s a true bonus and time for celebration.

Lorry Schoenly has written such a book that I recommend for all of us who practice in jails and prisons. This is a book that has universal applicability, whether you are a nurse, a practitioner, a mental health provider or an administrator. The name of the book is Correctional Health Care Patient Safety Handbook. You should read this book! Continue reading →

Game Changer! The New ACA/AHA Cholesterol Guidelines

Posted on January 24, 2015 by Jeffrey Keller MD

About a year ago, the American Heart Association released new cholesterol management guidelines. These guidelines changed how we practitioners should deal with cholesterol evaluation and management almost to a revolutionary degree. They are a BIG departure from past thinking. For example, under the old system, we practitioners were supposed to follow cholesterol labs. We were supposed to get LDL levels down below 100. Not anymore! In fact, under the new guidelines, once you have started someone on therapy, you really don’t have to check their cholesterol ever again! Really!

Also, the new guidelines say that there is basically only one therapy for almost all lipid patients: statins. According to the new guidelines, we should get rid of all other lipid therapies. Niacin? Throw it away. Gemfibrozil and fish oil? Get rid of them.

What about triglycerides? The new guidelines say that you should only treat hypertriglyceridemia with medications when the triglyceride level is greater than 1000mg/d. Holy cow, 1000! Where did that come from?

This document is almost revolutionary in its sweeping changes. It makes treating hyperlipidemia so very much easier. In my opinion, all correctional practitioners and nurses involved in chronic care clinics should know the new guidelines. If you have not already done so, you need to re-write your lipid protocol. Continue reading →

Grody Feet and Heel Cracks

Posted on November 17, 2014 by Jeffrey Keller MD

Back when I worked in the ER, we often would have patients come to the ER who were homeless or otherwise had not been taking care of themselves. Of particular concern was their feet—many had not removed their shoes for days or even weeks. When these shoes were removed, we often were confronted by a dreaded medical malady: Toxic Sock Syndrome. These feet could be unbelievably odiferous—I have seen hardened paramedics retch.

So we had to be careful. If a patient was suspected of having Toxic Shock Syndrome, shoes and socks would be quickly removed into a plastic bag and the feet immediately washed and covered with clean slippers.

That was about the end of ER involvement with poorly-cared-for feet. As an ER Doc, I never had to do much with the underlying foot disease.

The situation has been reversed now that I work in jails and prisons. I don’t have to deal with Toxic Sock Syndrome anymore. (I’m sure the booking deputies do, though. Bless them). Instead, a day or two later I typically am confronted in the jail medical clinic with the grody feet themselves. Here is a typical example:

The medical term for such feet is PalmoPlantar Keratoderma or PPK. Continue reading →

Jail Medicine

A Correctional Health Blog by Dr. Jeffrey Keller

Category Archives: Medical Practice