What are your thoughts?

Michelle Teasdale, DNP, APRN, FNP-C

Hello everyone,
I recently attended the National Commission on Correctional Health Care (NCCHC) conference in Las Vegas. One topic of discussion was transgender healthcare and housing recommendations in corrections. After the conference, I talked with medical providers and correctional employees about a few discussion points covered during the presentation. I received a variety of opinions on the topic. I have listed some of those discussion points and would like to know your thoughts.

1- Transgender individuals should be addressed by their chosen names (not their legal names) and correct pronouns. Should staff at the correctional facility be subject to legal or institutional repercussions if they do not comply with the inmate’s request? Why or why not?

2- Transgender inmates should be housed in areas of the same gender they identify without segregation or isolation from other inmates. Do you agree?

3- Suppose an inmate is incarcerated for a long period of time and during the incarceration, now identifies as transgender. Do you believe it should be the correctional facility’s responsibility to diagnose the individual with gender dysphoria, if it applies, and begin treatment? Do you foresee any legal challenges associated with such a change?

4- There have been some correctional facilities that have paid for gender reassignment surgery. Should this treatment be an option for all transgender individuals who meet surgical requirements while incarcerated? Should federal/community funding be used to directly pay for such services?

Case Report: An Acute Rash in a Patient with HIV

Michelle Teasdale, DNP, APRN, FNP-C


A 28-year-old male with a history of HIV presented to jail. During the prescreening process, he denied any symptoms of an acute illness or mental health condition and was booked into jail. A comprehensive nursing exam (CNE) was completed and notable for the following:

He was diagnosed with HIV in 2001 and has Bictegravir 50mg/emtricitabine 200mg/tenofovir 25mg once daily (Biktarvy) prescribed. The last dose was taken two weeks prior to presentation. He has no known allergies and no recent travel outside of the United States.

The patient has a 10-pack-years tobacco history. He drinks alcohol socially and has no history of illicit drug use. He has multiple male sexual partners, and his last sexual activity was one month prior to presentation. 

Physical Exam

Temperature, 98° F, Heart rate, 98 beats per minute, Blood pressure, 128/78 mm Hg, Respiratory rate, 16 breaths per minute, Oxygen saturation, 100% while breathing ambient air. He is well-appearing, well-nourished, alert and oriented, and in no acute distress. The review of systems (ROS) are negative per his report. All body systems during the head-to-toe examination are within normal limits. 

CNE Follow Up

An active Biktarvy prescription could not be verified. He was scheduled to follow up in the HIV clinic.

HIV Clinic Visit

The patient was evaluated in the HIV clinic two weeks after being booked into jail. He reported feeling well, without specific medical concerns. He tolerates Biktarvy without side effects. He denies fever, chills, or cough. The remainder of the ROS are negative, and all body systems are within normal limits.

The provider ordered a CD4/CD8 absolute and %, T-Cell Panel, an HIV viral load, and confirmation of prior Biktarvy prescription before starting.

Clinical Course

Biktarvy was initiated after evaluation in the HIV clinic. Eight days later, the patient discontinued Biktarvy due to a new rash. He was scheduled for a follow-up provider visit.

Provider Visit

Chief Complaint



The patient reported five days of a new onset rash involving the entire torso and upper extremities. No fever, chills, or difficulty swallowing. He otherwise feels well.


Dermatologic exam – Vesicular rash covering the trunk, upper, and lower extremities with sparing of the palms and soles. There was no evidence of mucosal or ocular involvement.

Lab Results

CD4 count 100 cells/µL

HIV RNA Quant 861,000 copies/mL

The provider sent him to the hospital. Do you know why?

Answer: the provider’s impression was disseminated zoster following immune reconstitution inflammatory syndrome in a patient with HIV and a CD4 count of 100. He found this quite concerning due to the possibility of secondary sequelae, including eye involvement and encephalitis. 

What is Immune Reconstitution Inflammatory Syndrome?

Immune Reconstitution Inflammatory Syndrome (IRIS) depicts a group of inflammatory disorders associated with worsening preexisting infectious processes following the initiation of antiretroviral therapy (ART) in patients infected with HIV. Preexisting infections in individuals with IRIS may have been previously identified and treated or could be subclinical and unmasked by the individual’s regained capacity to produce an inflammatory response. If immune function improves rapidly with ART initiation, systemic or local inflammatory reactions may occur at the site of underlying the infection (Wolfe, 2019).

Patient Risk Factors

  • Studies have demonstrated that lower CD4 cell counts or high HIV viral load at the time of ART initiation increase the risk of developing IRIS. The patient’s lab results revealed both.

The ER visit

Physical exam

All body systems are within normal limits with the following exception.

Skin – warm and dry. Notable lesions to arms, chest, back, small erythematous raised papular lesions. Some are scabbed and in various stages of healing.

Differential Diagnoses considered by the ER physician included chickenpox, mpox (formerly known as monkeypox), adverse reaction to Biktarvy, and syphilis.

The physician collaborated with an infectious disease specialist and an epidemiologist. It was determined that it was unlikely that Biktarvy caused the rash, and the medication should be continued. Testing for mpox, varicella, and syphilis was obtained.


Mpox is a zoonotic viral infection. Most cases have been identified in men who have sex with men. Close contact with an infected skin lesion during sexual contact is the most likely mode of transmission. Person-to-person transmission can also occur through large respiratory droplets. The incubation period is 7-10 days after exposure (Isaacs & Mitja, 2022).

Mpox has traditionally caused a systemic illness during the prodromal or early clinical stage, including fevers, chills, and myalgias. A characteristic rash develops helping, to differentiate it from other vesicular rashes. The rash materializes one to two days before or three to four days after the onset of the systemic symptoms and persists for two to three weeks (Isaacs & Mitja, 2022).

The rash associated with mpox usually begins as 2 to 5mm diameter macules that simultaneously develop on any part of the body. The lesions evolve into papules, vesicles, and then pseudo-pustules. The lesions are well-circumscribed, deep-seated, and often develop umbilication. One to two weeks after the onset of the rash, the lesions crust over, dry, and fall off. The rash is usually described as painful but can be pruritic during the healing phase (Isaacs & Mitja, 2022).

Changes during the Mpox 2022 outbreak

During the 2022 mpox outbreak, some patients presented with a rash but did not have systemic symptoms, and not all lesions were in the same stage of development (Isaacs & Mitja, 2022).

Patient Risk Factors

  • The patient reported he has multiple male sexual partners. 
  • Vesicular rash in varying stages of development.


Varicella-zoster virus (VZV) causes two recognizable diseases – chickenpox and shingles. Varicella is the primary infection and is known as chickenpox. The rash caused by chickenpox can occur anywhere on the body but is usually concentrated on the face and trunk. Vesicular lesions characterize the rash. The lesions are on an erythematous base and appear in different stages of development (Albrecht & Levin, 2022). 

During varicella, the virus establishes latency in the sensory ganglia and can become reactivated, resulting in herpes zoster, better known as shingles. The shingles rash occurs unilaterally in a single or two bordering dermatomes. The lesions are vesicular and painful. Systemic symptoms, such as fever, fatigue, or malaise, occur in less than twenty percent of patients (Albrecht & Levin, 2022).

Immunocompromised persons are at higher risk than the general population for VZV reactivation and the development of herpes zoster. The rate of complications, including herpes zoster keratitis, herpes zoster ophthalmicus, and encephalitis, are also significantly higher in immunosuppressed patients (Albrecht & Levin, 2022).

Patient Risk Factors

  • Immunocompromised
  • Biktarvy reinitiated, putting him at risk for IRIS/VZV virus vasculopathy. 
  • Vesicular rash in varying stages of development.


Syphilis is transmitted from person to person by direct contact with a sore, known as a chancre. Chancres are lesions that can occur inside or on the penis, vagina, anus, rectum, lips, or mouth and can be transferred during vaginal, anal, or oral sex (Hicks & Clement, 2022).

Primary syphilis: the initial sign of infection is a chancre that can appear 21 days after exposure at the inoculation site. Typically, it appears on the genitals but may develop at other sites, including the posterior pharynx, anus, or vagina (Hicks & Clement,2022). 

The lesion begins as a papule and advances to an ulcer. The 1 to 2cm ulcer has a raised, indurated margin and is painless. Since the sore is painless and may go unnoticed, many patients do not seek medical attention, increasing the risk of transmission. The chancre usually heals within three to six weeks, even without treatment. Primary syphilis can quickly become systemic and is the cause of secondary syphilis (Hicks & Clement, 2022). 

Secondary syphilis: Twenty-five percent of people, mainly patients who have not been treated, develop systemic illness representing secondary syphilis. This can occur within a few weeks to a few months after the development of the chancre (Hicks & Clement, 2022). 

Secondary syphilis may produce various signs and symptoms, such as fever, malaise, sore throat, myalgias, and weight loss. The most characteristic finding is a diffuse rash that can present in any form, although vesicular lesions are uncommon. The rash involves the trunk, extremities, palms, and soles. Involvement of the palms and soles is a crucial finding in diagnosing secondary syphilis; however, localized lesions may also occur. Secondary syphilis symptoms may resolve spontaneously without treatment. (Hicks & Clement, 2022). 

Patient Risk Factors

  • Patients with HIV are at higher risk for STIs.
  • Immunocompromised 
  • Rash

The Diagnosis – with lab results from the ER

Secondary Syphilis

He did not have any memory of a chancre and therefore did not know he had been infected. Although his rash was not characteristic of secondary syphilis, documentation shows that different presentations can be expected. 


The recovery of immunological function resulted in unmasking the unknown preexisting syphilis infection. He received the first Bicillin 2.4 million unit injection before he left the hospital. Two more doses were prescribed one week apart. Since ART can predispose patients with IRIS to opportunistic infections, he was also prescribed Bactrim prophylaxis for pneumocystis jirovecii pneumonia.

When he returned to jail, he was placed in isolation until the other test results were available. The results for varicella and mpox were negative. He completed treatment for syphilis and continued on Biktarvy without complications. He was released from jail before follow-up HIV labs could be obtained.

Is Heroin Ingestion the Get Out of Jail Free Card?

Michelle Teasdale, DNP, APRN, FNP-C

The opioid epidemic is an ongoing crisis in the United States. The epidemic began during the 1990s when the practice of prescribing opioids increased; however, inexpensive heroin and synthetic opioids have prolonged the epidemic. Given this situation, it is no surprise opioids are the most commonly reported drug used by the individuals incarcerated at the correctional facility where I practice.

During the intake process, many individuals will report they swallowed heroin before being arrested. This scenario is problematic for medical staff as they are forced to determine if the heroin was actually ingested, or if the disclosure was a fabrication. This is further complicated by the fact that heroin is generally distributed in a non-opaque container, generally latex or plastic, and is not easily visible by x-ray.

During this scenario, there are only two options, refuse to accept the individual into the jail until they are cleared at the hospital, or accept them with close monitoring. Due to limited resources, the former is often believed to be the safer practice. Of course, we want to provide safe medical care, however, the liability for this decision can be difficult and frustrating. Inmates have admitted to reporting the ingestion, hoping the arresting agency will not take them to jail or will release them from custody because the charges are generally not severe enough to justify the time and expense of a hospital visit. My colleagues and I would like to develop a safe process that can be used to reduce or even eliminate the “get out of jail free card” often employed to avoid incarceration.

Naturally, any drug ingestion can be critical. I have focused on heroin because it is the most reported drug ingestion we have encountered so far. Have you experienced similar reports of drug ingestion to avoid incarceration at your facility? If you have and the individual has been accepted, other than using the Clinical Opiate Withdrawal Scale (COWS), what additional practices, policies, or procedures are used in your facilities to ensure patient safety?

ACA Seeks Executive Director

ACA Seeks Executive Director – The American Correctional Association (ACA) located in Alexandria, Virginia, is seeking an Executive Director who serves as the chief operating officer and secretary for the association. The full job description and requirements for applying can be found on ACA’s website at www.aca.org. All applications must include the following: a copy of your resume or vitae; three or more professional references with contact information; and a three-page document on “why select me” for this position based on the job description and your professional experience. Interested applicants may apply by mailing a physical copy of the required documents to the American Correctional Association, Attn: Executive Office, 206 North Washington Street, Suite 200, Alexandria, VA  22314. Salary and benefits are negotiable. All applications must be received on or before February 11, 2022. Incomplete applications will not be considered. When applying, please include your email address to acknowledge receipt of your application.

Todd Wilcox, New JailMedicine Editor, The Seton I&D Technique

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:

Necessary equipment

  • Local anesthetic.  I generally use 1% lidocaine with epinephrine.
  • 5cc syringe with 18 g and 25-27 g needles
  • Chux pad
  • 4×4’s
  • #11 scalpel
  • Silicone vessel loops (we stock 2 sizes)
  • Noyes alligator forceps
  • Island gauze dressing

The Technique

  1. This technique does not require sterile technique or prepration.  It is a clean technique, not a sterile one. 
  2. The abscess is palpated and the edge of the abscess is identified in two spots 180° opposite each other.
  3. You can use a pen to draw on X at your marked spot.
  4. 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.
  5. A wheal of local anesthetic is raised at those two spots
  6. 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
  7. 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. 
  8. The teeth of the Noyes passer are then used to grab the silastic vessel loop and that is pulled back through the abscess cavity.
  9. The silastic vessel loop is then tied in a loose air knot with usually 6 to 8 throws of knots on top.
  10. The tails of the vessel loop are then cut leaving a very loose suture with the silastic vessel loop in the skin.
  11. An island dressing is applied over the top of this and the patient is free to go.
  12. The patient may shower and generally the only dressing necessary for this technique is an island dressing every day for the next few days.
  13. 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.
  14. 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.
  15. 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.

  1. 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.
  2. 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.
  3. 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.
  4. 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!

Scholarship Opportunity!

The National Commission on Correctional Health Care (NCCHC) recently established the NCCHC Correctional Health Foundation.  The mission of the Foundation is to champion the correctional health care field and serve the public by supporting research, professional education, scholarships, and patient reentry into the community. I am honored and proud to be part of the first Board of Directors of the Foundation.

Just this week, the Foundation announced that scholarships are available for the NCCHC Virtual National Conference in November.  Deadline for applications is September 30, 2020. Students, staff new to corrections and individuals who have never attended an NCCHC conference are strongly encouraged to apply, but all are welcome. 

Find out more about the Foundation and the scholarship by visiting: www.NCCHC.org/Foundation

ACCP Position Paper on Hepatitis C Infection

Recently (just before the Covid-19 tsunami hit) I was privileged to chair the American College of Correctional Physicians (ACCP) committee tasked with writing an official position paper on the treatment of Hepatitis C infection in corrections. The exact wording of the paper required some delicacy because treating Hepatitis C in incarcerated inmates can be controversial. No one disagrees that patients with Hepatitis C infection should be treated, whether incarcerated or in the free world, but because the drugs used to treat Hepatitis C are so horrifically expensive. Some state legislatures, which authorize funds for inmate medical care in their prison systems, have been reluctant to fully fund Hepatitis C treatment. More on this in a future post. In the meantime. I believe this is an important document that all correctional medical professionals should read.

Continue reading

Top Five Articles from 2018

2018 was a great year for JailMedicine! Noteworthy events from the year include:

I introduced a new feature–Sample Guidelines–which turned out to be very popular. I intend to add many more sample guidelines this year. Please let me know what guidelines you would like to see!

I began a new blog on MedPage Today entitled “Doing Time: Healthcare Behind Bars” (found here) that introduces our world of Correctional Medicine to outside medical professionals who have no idea what we do. This has also been well read.

Readership increased substantially in 2018. This may be because I published more articles . . . Thank you to everyone who read JailMedicine this year!

Without further ado, these are the five most read articles from 2018:

Abscess Incision and Drainage, a Photographic Tutorial

I was given the opportunity to create a tutorial of the classic method of lancing an abscess when a friend of mine came to my office with a great cutaneous abscess on his back.  This has been, by far, the most read JailMedicine article of all time.

Removing Microdermal Implants, A Photographic Tutorial

Microdermal implants are so common as to be ubiquitous.  Almost all of th jewels can be unscrewed from the base, which is my preferred way to deal with them in a jail setting.  However, occasionally, patients want to have the implant removed entirely. It is not hard, but many practitioners have never done it and so do not know how.

A Better Way to Drain Abscesses: The Berlin Technique

I have a confession to make.  I no longer (usually) incise and drain abscesses in the manner that I taught on the photographic tutorial above.  My dermatologist friend and colleague, Neelie Berlin, showed me this nifty technique that uses a 4mm punch biopsy tool  It is quicker, easier and just as effective for the majority of uncomplicated skin abscesses you will see in your clinics.  You just have to order the punch biopsy tool!

What’s the most cost-effective way to treat scabies? The answer might surprise you

Scabies is so common in jails that every jail medical professional should know how to recognize this itchy little pest. It is not too hard as this post points out.  Also, It turns out that treating scabies with oral ivermectin is less expensive and easier than using topical permethrin cream.

Medications at High Risk for Diversion and Abuse In Correctional Facilities

Many seemingly benign medications are commonly diverted and abused in correctional facilities.  The risk of abuse for some of them so overwhelms any potential benefits of these drugs that I argue that they should rarely be used in jails and prisons.

What was your favorite post from JailMedicine?  What should I address in future articles? Please comment!