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 →
Ingrown toenails are a common presenting complaint in my jail medical clinics, just as they were when I worked in the ER back-in-the-day. Of course, not all toe infections are due to an ingrown toenail (which I will talk about later), but when an ingrown toenail is present, removal of the ingrown nail spicula is instantly curative. And unless you remove the ingrown toenail, the toe usually will just smolder along and not get better. So knowing how to properly remove a toenail is a great and useful thing.
However, I have heard that some Correctional Practitioners are unfamiliar and uncomfortable with the procedure of toenail removal and so when faced with a nail that needs to come off, they instead: 1. Leave the nail on to fester, 2. Over-prescribe unnecessary antibiotics, or 3. Send correctional patients to a foot surgeon to have this simple procedure done. All of these are poor medical practice, in my opinion.
Like abscess I&D that I have written about previously, toenail removal seems to be a daunting procedure, but actually is quite simple. Of course, any medical procedure can be done incorrectly or inefficiently. Today’s JailMedicine post is a tutorial on how to cure ingrown nails by performing a simple toenail removal. Continue reading →
Skin abscesses are quite common in correctional facilities, especially in the MRSA era, and so all correctional practitioners need to be comfortable with the procedure of abscess incision and drainage, also known as “lancing” the abscess. Also “Let’s cut that sucker open.” However, I’m going to be professional and call this procedure “I&D” for “Incision and Drainage.”
When I was just starting out in emergency medicine, I&D seemed to be quite a daunting task. I was afraid of making a mistake and hurting someone or making them worse. However, in actual fact, I&D is quite easy. You can potentially hurt people more by not doing an I&D than by doing one.
But, like all medical procedures, it is possible to do the procedure poorly and inefficiently or to make outright mistakes. The subject of today’s post is how to do a simple I&D of a skin abscess. The opportunity to take pictures of the procedure arose when a fireman friend of mine walked in to my office and asked me to look at a lump on his back that had been there for a few days. It was quite sore. Here is a picture of the lump:
This appears to me to be a MRSA abscess. Statistically, MRSA causes approximately 75% of all community acquired skin abscesses. But beyond the statistical likelihood, this looks like a MRSA abscess. It has lots of pus for its size along with a central area where the lesion is “pointing.” This appearance is commonly mistaken for a “spider bite” by the lay public.
Why did my friend get a MRSA lesion on his back? I don’t know. Why does one member of a family get strep throat but not the others? It just happens. Usually, the only way to pinpoint the source is when multiple patients with a common background get MRSA, like members of a wrestling team or inmates housed in the same dorm. A single, isolated case like this just happens—and not infrequently.
The treatment for MRSA abscess is Incision and Drainage, so I am going to cut this sucker open to let it drain—oops! I mean I am going to perform an I&D procedure and document the process with pictures and discuss each step. The process of I&D consists of these steps:
Skin cleaning. I did this using alcohol wipes. It is important to remember that this is not a sterile procedure—even if you do a surgically prep and drape the skin and use sterile gloves, they will not remain sterile once everything is covered by pus from the abscess! Instead, this is a clean procedure. You want everything to be clean, but you do not have to perform a formal surgical prep.
Anesthesia. I prefer to use 0.25% bupivicaine (Marcaine) with epinephrine. Why Marcaine instead of lidocaine? Well, they are comparable in price and Marcaine has the advantage of lasting 3-4 times longer, so the area stays numb for 12-16 hours instead of 4 hours. Why use epinephrine? The main reason to use epinephrine is that it constricts skin blood vessels so there is much less bleeding. This makes the procedure that much easier to perform. Epi also makes the anesthesia last longer—another bonus for the patient!
Make the incision. I prefer to use a #15 blade scalpel rather than the traditional #11 blade—but either will work. The most common mistake made when incising an abscess is not to make the incision big enough. The incision needs to be long enough and deep enough to allow access to the abscess cavity later, when you explore the abscess cavity. Note that my incision stretches the whole diameter of the abscess—all the way from the top edge of redness to the bottom edge of redness. Notice also that I have chosen in this case to make the incision run across the lines of tension of the skin by incising from top to bottom. Typically, you would make an incision run the same direction as the skin creases if you want to minimize the scar. I don’t care too much about a scar in this case, since the lesion is on the patient’s back. I am more concerned with adequate drainage of the wound. By making the incision perpendicular to the creases, the skin will naturally gape open after the procedure and allow pus to drain. Not allowing the skin edges to touch and potentially re-seal is also the reason for placing packing in the wound, which we will discuss later.
Squeeze out the pus.This abscess had quite a bit of pus. By the way, you do not have to routinely send this pus for culture in the majority of young healthy patients, especially if you are not going to prescribe an antibiotic (discussed later). Culture is a good idea in complicated cases, such as immunocompromised patients, or large complicated abscesses.
Explore the abscess cavity. There are several reasons to do this. The first is to see how deep the abscess goes. Some abscesses are like icebergs—what you see at the surface is only a small portion of the whole abscess. Some can run amazingly deep. You should find the full extent of the abscess cavity. Second, many abscesses have multiple chambers and your incision may have only drained one. By exploring the cavity, you will break any remaining abscess walls and make sure the entire abscess has drained. Finally, many abscesses have thick, adherent pus stuck to the walls that does not drain easily. By rubbing the inner walls of the abscess, you will loosen that thick pus and get it out. How to explore the abscess cavity depends on the abscess size. I have found that the best instrument for exploring bigger abscess is my gloved finger, as I have done here (as long as you are sure there are no foreign bodies in the abscess). I have seen surgeons get their whole hand inside really big abscesses (of course abscesses that big probably should be sent to a surgeon). On the other hand, you may not be able to get your finger into a small abscess. A curved mosquito forceps with some gauze at the tip works well in those cases.
Irrigate the interior of the abscess with saline.This is done to make sure that we have all of the pus out. When the saline draining out of the abscess is clear, the abscess cavity is clean.
Insert a pack. Abscess packing is perhaps the single most misunderstood aspect of abscess I&D. The purpose of the packing is to prevent the skin edges from re-sealing. It is a mistake to think that the packing aids healing. It does not. There needs to be enough packing in the interior of the abscess cavity to prevent the wick from falling out, but there is no benefit to stuffing a ton of packing into the abscess. In fact, that is detrimental, because the packing is a foreign body and because if the packing is packed so tightly so as to exert pressure, it can cause tissue necrosis. In fact, not every abscess needs to be packed. If the opening is gaping so widely that there is little chance of the edges re-sealing together, there may be no need for packing. This point is so important that I will say it again: abscess packing material is a foreign body. It can delay healing and resolution of the abscess. Its only function is to prevent the skin edges from re-sealing. The packing I place today will be removed tomorrow. I don’t want it in there very long. It is a foreign body.
Place a dressing.The first 24 hours after an I&D, the abscess will continue to weep, so it is nice to have an occlusive dressing to prevent he wound from weeping all over clothes and bedding and the inmate’s roommate.
The next day, remove the packing.Since the packing is a foreign body, it should be removed as quickly as possible. Notice that this abscess seems reasonably dry after one day. If the wound were still draining pus, that might mean that I had not fully cleaned out the abscess interior, and I might need to re-explore the abscess to see what I missed.
Leave the abscess open. Patients at this stage can shower and I encourage them to let the water wash out the interior of the cavity. Over the next week or two, the abscess will heal in from the bottom out.
Antibiotics? There is a large body of literature that says antibiotics should not be routinely prescribed for MRSA abscesses as long as they can be fully drained and as long as the patient is otherwise healthy and there is no accompanying cellulitis. This patient is healthy and I see no cellulitis surrounding the abscess, so I am not going to use antibiotics.
This entire procedure took literally about 10 minutes to do. It turned out well.
ADDENDUM (12/12/12) This is a picture of the site one week post procedure. It appears to be healing well. The skin rash reaction to the dressing tape looks worse than the wound!
Mandatory disclaimer: The technique I used here is a result of my Emergency Medicine training, my experience and my preferences. Other practitioners may use other techniques that are just as effective. Some may even disagree with what I have said here! You should develop your own technique based on your training, experience and preferences! A very good official source for the technique of abscess I&D is Roberts: Clinical Procedures in Emergency Medicine, 5th ed. Chapter 37, Incision and Drainage. Also, I am talking here about simple abscesses. Abscesses in complicated areas such as the hands, neck or anus or abscesses of the face where the inevitable procedural scar will be visible may be best sent to a specialist to drain.
Do you have a different technique that you use to I&D abscesses? Please comment!