The recent suicide of Jeffrey Epstein while in custody at a Manhattan
detention facility has focused intense media scrutiny into jail suicide
prevention procedures. Suicide is the biggest cause of death in jails in the
United States—by far. Because of this,
all jails (including the facility where Mr. Epstein was housed) have a suicide
prevention policy. Since the suicide prevention process was an
epic failure at the facility where Mr. Epstein was housed, it might be useful
to discuss how a jail suicide prevention program is supposed to work.
I will be meeting a new jail patient with multiple medical
problems today in my clinic. I know this
much before I even meet him: He will
almost certainly be scared, especially if this is the first time he has ever
been to jail. He will likely be
suspicious of me. He may even be downright hostile. I know this because this is
the norm for correctional medicine. I can’t be an effective doctor unless I can
turn this attitude around.
Consider the situation from my patient’s perspective. Prior to seeing me, he was arrested,
handcuffed and driven to jail in a police car.
Once at the jail, he was thoroughly searched (spread-eagle against the
wall), fingerprinted and had his “mug shot” taken. His clothes were taken away and he was given
old jail clothes (including used underwear).
He was placed in a concrete cell.
Now he is summoned by a correctional deputy and told (not asked) to go
to the medical clinic.
He did not choose me to be his doctor. Though he doesn’t know anything about me, he
has no choice but to see me for his medical care. Not only did he did not
choose me; he cannot fire me or see anyone else. He may fear that I am not a competent doctor;
otherwise why would I be practicing in a jail?
This is the attitude that I have to overcome. How to do this is an essential skill for
correctional practitioners. And, of course, the single most important encounter
is the first one. A negative first impression is hard to overcome–and I am already
starting out at a disadvantage. What I
have to do in only a few minutes is convince my patient that I am a legitimate
medical doctor and that I care about him. I have learned in many years of doing
this that these things are essential:
Perhaps the strangest aspect of practicing medicine in a jail or prison is “comfort requests.” This is when an inmate comes to the medical practitioner asking for something like a second mattress, the right to wear their own shoes, a second pillow, a second blanket, etc. This, of course, never happens in an outside medical practice. When was the last time you heard of a patient asking for a prescription for a pillow? Yet such requests are extremely common in correctional medicine. You might think, “Well, just give them the second pillow—what harm can it cause?” But it is not that simple. Like every medical issue, there is a right way and a wrong way to handle these requests. To understand why, let’s consider the single most commonly requested comfort item in a correctional medical clinic: a second mattress.
Consider the case of a 60-year-old patient I will call “Library Man.” While at the public library, Library Man took off most of his clothes and was talking loudly to no one in particular. The police were called, of course. He was charged with disturbing the peace and brought to my jail.
Jails basically have three types of housing areas. First are dormitory-style rooms with 60-100 residents. Library Man cannot be housed there—the young aggressive inmates would prey on him. Second are smaller cells that hold two to four inmates. The problem with these cells is that even if the jail could guarantee gentle cell mates, it would be hard to monitor Library Man in such cells. Such cells tend to be in out-of-the-way places and have small windows on the doors. The only place that Library Man can be reasonably housed in most jails is “Special Housing,” which refers in this case to a single-man isolation cell with lots of plexiglass to allow easy observation. Such rooms are designed to have nothing that someone could use to harm themselves, so they are made entirely of concrete and steel—even the bed. This is where Library man ends up—basically in a large concrete box.
Unfortunately, this is not a good place for Library Man to be. You may have guessed that Library Man is a homeless schizophrenic who had gone off of his meds. He is harmless–certainly not a danger to himself or to others. In his psychotic state, he does not understand why he was arrested and jailed. Library Man would benefit from familiar surroundings and normal social interaction with people. He will get neither of these in the alien and sterile environment of his concrete isolation cell.Continue reading →
One thing I always tell practitioners who are beginning a jail medical practice: you’re going to see a lot of withdrawal cases — study up! In particular, since the opioid epidemic hit, the number of patients I’ve seen in my jails withdrawing from heroin and other opioids of all stripes has skyrocketed. I’ve seen enough patients withdrawing from opioids that I think I am reasonably knowledgeable on the topic. Because of this, I was quite surprised when I ran across this sentence in a recent edition of The Medical Letter:
The problem is that although this sentence seems quite self-assured, it is flat out wrong. In fact, it is not just wrong; it is also dangerous. People do die from opioid withdrawal. I know of several such cases from my work with jails. Opioid withdrawal needs to be recognized as a potentially life-threatening condition, just like alcohol withdrawal and benzodiazepine withdrawal.Continue reading →
I have begun a new blog that is being published on MedPage Today entitled “Doing Time: Healthcare Behind Bars.” The difference between that blog and JailMedicine is the audience. JailMedicine is written for medical professionals already working in a jail or prison (bless us all!). The MedPage Today blog is written for medical professionals who have no idea what Correctional Medicine is all about. The first post of Doing Time follows:Continue reading →
