Hi, my name is Todd R. Wilcox, MD and I want to introduce myself as the incoming editor of jailmedicine.com. I have followed Dr. Keller’s work and this website since it was first published and I’ve been a big fan of the level of practicality and informative insights he has brought to the practice of medicine in correctional facilities. I hope to be able to continue that trend and to broaden the input with some additional specialists who see incarcerated patients and manage their unique healthcare needs. I have worked in correctional healthcare as a physician for 26 years and I am the medical director of the Salt Lake County Jail System in Salt Lake City, UT. I completed my undergraduate work at Duke University and then attended medical school at Vanderbilt University School of Medicine. I also have a Masters of Business Administration from the University of Utah. I am board certified in Urgent Care Medicine and my clinical interests include wound care, pain management, orthopedic injuries, and HIV medicine. I am a frequent lecturer at NCCHC, ACA, AJA, and the National Sheriff’s Association and I look forward to engaging with colleagues who are similarly interested in the challenges of delivering healthcare to our incarcerated patients.
Skin Abscess Treatment with the Seton Technique
In correctional health settings, we encounter a lot of skin abscesses on various parts of the body. The traditional technique of doing an incision and drainage (I&D) of an abscess has many limitations which has prompted the development of a new technique called a seton placement. This technique originally started with the colorectal surgeons who were treating pilonidal cysts and peri-rectal abscesses and it has been adopted for skin abscesses by the emergency medicine physicians.
A traditional I&D is generally accomplished using lidocaine infiltrated into the skin and into the abscess cavity and then a number 11 or 15 blade is used to open up the entire abscess and squeeze all of the pus out which then creates a cavity that needs to be packed. While this technique is effective and is the traditional treatment for skin abscesses, there are many limitations for using this technique in a correctional setting.
it is difficult to anesthetize an abscess due to the acidic nature of the pus that deactivates the local anesthetic
I&D technique is generally very painful for the patient
I&D tends to be very messy with a lot of pus and blood produced that is often under pressure and squirts all over
the wound backings that are necessary to get this wound to heal by secondary intention are painful for the patient
the wound packings take a lot of time for the nursing staff
the cosmetic result is unfavorable
the total treatment time to get a wound to heal by secondary intention is often two weeks or more
The new technique of seton placement was designed to address many of these shortcomings. The technique is described below:
Local anesthetic. I generally use 1% lidocaine with epinephrine.
5cc syringe with 18 g and 25-27 g needles
Silicone vessel loops (we stock 2 sizes)
Noyes alligator forceps
Island gauze dressing
This technique does not require sterile technique or prepration. It is a clean technique, not a sterile one.
The abscess is palpated and the edge of the abscess is identified in two spots 180° opposite each other.
You can use a pen to draw on X at your marked spot.
In identifying the two spots for the incisions it is important to locate one of them at the most dependent area of the abscess so that drainage of the entire abscess will occur.
A wheal of local anesthetic is raised at those two spots
A number 11 blade is then used with the cutting edge facing away from the body to make two small stab incisions at the identified spots and they need to extend into the abscess cavity completely. This should result in a return of pus and blood as the scalpel is taken out. It is much easier to shield and divert the pus in this technique compared to a traditional I&D
Once the two incisions are made, a Noyes passer is used to connect the two incisions and the passer goes in one incision, through the middle of the abscess cavity, and then out the other incision. A Noyes passer is much easier to use and to pass than a hemostat, but you can use a hemostat if needed. Your incision holes will need to be bigger to accommodate the width of the hemostat.
The teeth of the Noyes passer are then used to grab the silastic vessel loop and that is pulled back through the abscess cavity.
The silastic vessel loop is then tied in a loose air knot with usually 6 to 8 throws of knots on top.
The tails of the vessel loop are then cut leaving a very loose suture with the silastic vessel loop in the skin.
An island dressing is applied over the top of this and the patient is free to go.
The patient may shower and generally the only dressing necessary for this technique is an island dressing every day for the next few days.
The patient is instructed to grasp the knot and move the silastic loop back and forth once a day to break up any crusting or adhesions to keep the holes open.
The general order for removal is done on day five and a nurse goes and clips the silastic loop with a scissor and removes it just like a suture.
By day five the abscess is generally completely resolved and the overlying skin has adhered back down to the deeper tissue and the treatment for the abscess is resolved at that time.
This technique affords many advantages over the traditional technique:
Because you are anesthetizing the very edge of the abscess you are actually anesthetizing normal skin which is much easier to achieve good anesthesia with a local anesthetic than attempting to anesthetize the top of an abscess.
Properly done, this technique is almost painless for the patient.
From a provider standpoint, this technique is far faster than doing a traditional I&D. In my experience I can do a seton loop placement in about one third the time it would take me to do a traditional I&D.
With this technique, the initial rush of pus and blood can be controlled and it is much less messy for everyone and the risk of an exposure is much less.
Because the skin over the top of the abscess cavity remains intact and vascularized, there is no need for this wound to heal by secondary intent. This results in a much faster healing of the abscess.
The post technique nursing care is virtually nothing. All you have to do is provide a Band-Aid or an island dressing to put over the top of the seton for five days and the patient can apply that themselves after they shower. Your nurses will thank you profusely for not making them pack a big abscess cavity.
Because the skin overlying the abscess is not cut, the cosmetic result from this technique is substantially superior to a traditional I&D.
The preceding description is a basic description of how this technique is done. Once you gain experience there are some advanced hints and tricks that are possible to use with this technique.
I generally do not use a pen to place an X on the skin except in unusual circumstances where the placement of the anesthesia will obscure the edge border. This typically happens on the thicker skin of the face. Generally my technique uses lidocaine with epinephrine and I utilize the placement of the lidocaine with epinephrine to make my mark for me because the vasoconstrictive effects of the epinephrine will make it very obvious where to make your incision.
Most abscesses require the placement of one seton through the abscess. There are occasionally abscesses that have loculations or are large enough that additional setons need to be placed.
I have use this technique with very large abscesses in breast tissue a well as over the deltoid and in those the vessel loops are not large enough to accomplish the drainage. In larger areas I have used sterile tourniquets to place through the abscess cavity as my seton and that has worked beautifully.
For simple abscesses, I have not found antibiotics to be necessary above and beyond the drainage technique for complete resolution of the abscess. Clearly this is a matter of professional judgment as well as anatomy, and there are certain abscess presentations where supplemental antibiotics would be advisable. There is some evidence in the emergency medicine literature supporting adjunctive use of anbiotics for some clinical presentations.
The American College of correctional physicians has a video of this technique on their website.
What technique do you use to I&D abscesses? Please comment!
A few weeks ago, I received a request from a psychiatry resident working at a state prison about the use of restraints with patients who engage in severe self-injury. He was looking for guidance on the use of physical restraints with this population in prison. He noted that his role of ordering and monitoring patients in restraints caused him to feel more like a provider for the facility, rather than for the patient. I shared with him with the best resources I know – Resource Document on the Use of Restraint and Seclusion in Correctional Mental Health Care (http://jaapl.org/content/35/4/417) as well as Dr. Applebaum’s commentary on the same (http://jaapl.org/content/jaapl/35/4/431.full.pdf). As I sat down to write this, I intended to discuss the rules and regulations surrounding restraint (e.g., Center for Medicare and Medicaid Services (CMS) 42 CFR § 482.13) but I stopped myself.
The inquiry was not about regulations and requirements for the use of restraints. The question was about patient care.
It was a holiday weekend in the middle of the night. The booking area of the jail was a big, open, noisy pit with people sitting in plastic chairs, watching TV or on phones and the officers either behind desks or circling the perimeter. It was filling up. A staff member was completing initial mental health screenings in a corner of the open room, up on a platform and behind a computer. She had the electronic health record open to the mental health screening form and she was going through each “yes/no” question, reading from the computer screen and not looking at the recently arrested individual, a young man picked up on a possession charge.
“Are you currently taking any medications for mental health
“Have you ever been hospitalized for mental health
“Are you currently thinking about hurting or killing yourself?” Pause. Swallow. “No.”
“Have you ever been treated for withdrawal from drugs or
She missed it. She missed the pause; she missed the swallow.
One of the consequences of the heroin epidemic we all are experiencing is a marked increase in the number of skin abscesses presenting to the jail medical clinics. Jails have always had to deal with skin abscesses. In fact, the single most popular JailMedicine post has been the Photographic Tutorial on Abscess I&D (found here). But since the heroin epidemic, the number of skin abscess we see has exploded. It is not unusual nowadays to lance an abscess every day!
The reason for this big increase in skin infections, of course, is that heroin users tend to share needles to shoot up, and these dirty needles leave behind the bugs that cause abscesses. And since shooting up causes the abscesses, they tend to be found where addicts commonly shoot up–like the inner elbow, the forearm and even overlying the jugular veins of the neck.
Fortunately, just in time for this onslaught of abscesses, my good friend Neelie Berlin PA taught me a new method of lancing simple abscesses that is quicker and easier—yet just as effective—as the method I had been using for my entire career. I’m going to call this new method of draining abscesses “The Berlin Method.”
Who says you can’t teach an old Doc new tricks? I have wholeheartedly gone over to the Berlin procedure. It is THE method I use now to drain simple abscesses.
Today’s JailMedicine post is a pictographic tutorial on how to do this new easier method of lancing simple abscesses.Continue reading →
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?
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
A couple of years ago, I first started to see microdermal implants in my jail patients. This is, of course, jewelry that is implanted in the skin. These have become so popular as to be almost universal. If you work in a jail or prison (or even if you have looked around at your local grocery store), you certainly have seen these. Microdermal implants can be problematic in correctional settings, because they cannot be easily removed like the older bolts and rings. Microdermal implants are imbedded in the skin, and removal requires making an incision to extract them.
But in corrections, even though it is difficult, microdermal implants often must be removed, either as a security issue or because the patient requests that they be removed. Nowadays, these implants are so common that all correctional practitioners really should know how to deal with microdermal jewelry. But most of us were never taught how to do this in our training! I certainly never learned about these in my residency training. Such a thing would have been inconceivable back then. Cutting edge fashion in those days was long hair and grungy jeans!
So I was grateful when an opportunity for education presented itself recently. A friend of mine asked me if I would remove two of her micro dermal implants and kindly consented to have the procedure photographed. Todays JailMedicine post is a photographic tutorial on how to remove microdermal implants.Continue reading →
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 →
The question of whether a seizure-like event is a true epileptic seizure or some type of pseudoseizure is often very hard to sort out. Oftentimes (in fact, most of the time) these events do not happen in front of us. We just hear reports from the deputies of “something happening–looked like a seizure.” Or perhaps the patient himself will tell us that he had an seizure, like the patient I saw recently who told me “I’ve had four seizures this week.” Of course all of them were un-witnessed by anyone else.
Even though you might suspect that these un-witnessed seizure-like events are pseudoseizures, you should be very cautious about labeling such events “fake.” The absolute worst mistake that you as a medical provider can make in these cases is to declare an event “fake”—and be wrong. Until you are very sure, it is better to assume that un-witnessed events are real–or at least keep that possibility in the forefront of your mind. Until you have more evidence, you just don’t know for sure.
That is why it is so valuable when a patient has one of these seizure-like events right in front of you. This is the one opportunity to use objective findings to distinguish a true epileptic seizure from a pseudoseizure. I discussed in my last post the various differences in presentation between epileptic seizures and pseudoseizures, such as the nature of the shaking, eye deviation and a post-ictal period. Unfortunately, however, none of these findings are perfect.Continue reading →
You are called by jail deputies to see a patient who had a short seizure and now is having another. The patient has only been in jail for a couple of days. He did not mention a seizure disorder at booking. He was arrested on a meth charge.
When you arrive, the patient is on the floor of the dorm, unresponsive and twitching. What do you do?
The diagnostic problem here is whether this is a true epileptic seizure or whether this is one of the various kinds of pseudoseizure. Accurate diagnosis is important because the treatment for the two conditions is so different.
Two epileptic seizures in short succession should make you think about status epilepticus and calling an ambulance. Even if the seizure stopped and you didn’t send this patient to the hospital, you would want a detailed examination in clinic to determine why these seizures happened. Is this a manifestation of some type of withdrawal, such as alcohol withdrawal? Does he have a seizure disorder that he did not tell you about before? You might consider a benzodiazepine like Ativan acutely and an anti-seizure drug like phenytoin. Down the road, you might want to do a work up, such as blood work, an EEG and maybe even a specialist referral.
On the other hand, if this is a seizure look-alike such as a Psychogenic Non-Epileptic Seizure (PNES), your treatment algorhythm would look much different. Then, your goal is just to stop the event and hopefully, be able to intervene in some way (counseling?) to prevent these from happening in the future. No ER visit. No seizure drugs. No EEG etc.
To get the diagnosis wrong—either way—would be to treat the patient inappropriately and perhaps even to harm the patient. So, accurate diagnosis is paramount.
It turns out that there are several observations, “field tests” and tools that can be useful in differentiating true epileptic seizures from pseudoseizures. There are even lab tests that can be useful! Some of these are much more reliable and accurate than others and I will point these out. Continue reading →