What is the most common mistake made when treating
withdrawal in a correctional facility?
Consider these two patients:
A jail patient booked yesterday is referred to
medical because of a history of drinking.
He has a mild hand tremor and “the look” of a heavy drinker. But he says
he feels fine and has no complaints. His blood pressure is 158/96 and his heart
rate is 94.
A newly booked jail patient says that she is
going to go through heroin withdrawal. She
is nauseated but still eating and has no gooseflesh or rhinorrhea. Her heart rate mildly elevated.
In many jails, neither of these patients would be started on treatment for withdrawal at their first visit to medical. But this would be a mistake! Both patients should be started on treatment for withdrawal immediately.
The most common mistake made when treating withdrawal in a jail is not to treat the withdrawal at all!
Both of these patients have the potential to slide downhill rapidly. And in both cases, the potential benefits of starting treatment far, far outweigh any potential liability.
I am seeing a 52-year-old male in my jail medical clinic who
was booked yesterday on a felony DUI charge.
He says he drinks “a lot of beer” but denies having a drinking problem. He is cranky and not really cooperative. He does not want to be here. However, the deputies tell me that he did not
sleep much last night and did not eat breakfast. I note that he has a mild hand tremor and a
heart rate of 108. According to the
clinical Institute Withdrawal Assessment for Alcohol–revised version (the most
common tool used in the United States to assess the severity of alcohol
withdrawal since 1989) my patient needs no treatment for alcohol withdrawal. But this is wrong! In actuality, my patient is experiencing
moderate withdrawal and should be treated immediately and aggressively.
Using CIWA is like
using a wrench to pound in a nail. It
can be done, but it is not really efficient or accurate. A different tool (a hammer) could drive the nail
much more quickly and effectively. CIWA is simply not the right tool to assess
alcohol withdrawal. We should be using
I had a lot to learn when I began practicing medicine in county jails. One of the most important of those lessons was how properly to assess and manage alcohol withdrawal. In my previous life as an ER physician, I had seen a few alcohol withdrawal patients and even one or two cases of DTs. I thought I knew what I was doing. Wrong-o! I was first unprepared for the sheer number of alcohol withdrawal patients I would see as a correctional physician. Alcohol withdrawal in jails is simply very common.
But I was also unprepared because much of what I had been taught about alcohol withdrawal was inaccurate or misleading. Nothing teaches like experience! After many years of treating a lot of alcohol withdrawal, I have gained some insights.Continue reading →
My good friend Al Cichon wrote the following comments to me about my article on the 10 Point Pain Scale.
Use of a ‘scale’ to measure subjective factors is a true oxymoron (heavy on the moron part). The ‘fifth vital sign’ is a misdirected effort to solve a true quality care problem – in my opinion. Vital Signs are objective (as in measurable) indicators that have been demonstrated to provide consistently valid data for patient care.
JCAHO has imposed the ‘Pain Scale’ in an effort to assure that the assessment of pain will be factored into patient care. Unfortunately, it is a bureaucratic response to a clinical situation – if it can be made to be measurable (regardless of practical validity) it can be enforced. My apologies to proponents and defenders – but no matter how well intended; it is still dysfunctional.
Yet, we are obliged to employ some process of assessment to determine the impact of subjective symptoms in an efficient / effective manner. The many schemes (Pain 1-10; Cardiac pain 1-5; etc.) developed have achieved relative success / adoption / adaptation. It does seem that these processes have provided some benefit – yet they all suffer from the same susceptibility – subjectivity. Whether you are working in corrections (where any subjective report must be verified) or the community (where verification is not always considered) any of these schemes has the same risk – because there is no objective validation.
One possible option to stabilize the use of any such scale is some method of anchoring the initial or end point of the scale. That would then provide a somewhat stable reference for guiding care and transmitting information (about the patient) to other providers. Also, this mechanism can be employed in other subjective areas.
Begin with asking the patient – ‘What is the worst pain you have ever experienced?’ (the response is usually associated with fractures, renal calculi, child-birth, etc.) Now, lets’ label that as a 10 (or 5) and now –‘What is the discomfort you have now in comparison to that prior event?’ Then document the exchange in the record: Worst Pain: fractured wrist – 10); Current Pain: pulled muscle – 7. Now, no matter the number system you have an ‘anchor’ to both the scale and the present condition that can be related to the care process and others. It is important to document the ‘source’ of pain too – as this may be quite useful if you are explaining the case later (DOC, court, etc.)
One variant of this is: If you had a ‘bucket labeled depression and a stick marked off from 0 to 10 what is the worst you’ve ever felt and when”? The response will then provide an anchor (9 when I was admitted to the hospital after trying to kill myself). Additional questions are: How deep is that bucket now? Has it ever been at 0? If I could make it happen (wave magic wand) and get you released and home now – what would it be? (interestingly it can go up with release for many reasons)
When you ‘anchor’ the ‘pain scale’ it establishes the assessment in a relatable setting and can be quite helpful in guiding patient care. The ‘anchor’ can also be quite useful in discerning the ‘historical validity’ of the case as well – ‘Doc when I had that car accident with multiple fractures it was a 10; now my sprained (non-swollen, non-bruised) ankle is a 10 too!’
Clinical judgment is always the most important skill in any patient care situation. The data subjective & objective is helpful but must be understood / applied in the clinical context.
Also confounding the assessment is the different types of acute / chronic discomfort (myofascial, neuropathic, visceral). As important as assessing the level of pain is the type – physiologic source – since it is critical in guiding treatment.
As noted – ‘chronic pain’ is better measures by an assessment of the patients ADL (what daily activities are disrupted and is that new). If a patient can function (nutrition, hygiene, elimination) and participate in some activities then treatment of the physiologic cause is the most important clinical consideration.
Just because you assign a number to a complaint, that does not make it objective. Because each of these scoring systems assigns a number to the complaint, there is a tendency to think of them as objective rather than subjective. But as Al points out, this is not the case. There is no real difference between someone who says his pain is “a six” and someone who says that he has “moderate pain.”
In order for a subjective scoring system to work, it needs to be “anchored” in some way. Al anchors the 10-Point Pain scale on the patient’s own worst experience. Another commonly used clinical pain scale, the Visual Analogue Pain Scale, anchors the scale onto facial expressions. The more “anchored” a system is, the better it is. The less anchored it is, the less useful it will be.
The more numbers in the scoring system, the less reliable it becomes. Let’s say instead of a 10-Point Pain Score, we used a 1000-point pain score and were asking patients “would you say your pain is a 671 or a 672?” Of course, a pain score of “672” gives us no more useful information than a “6.” In fact, it gives us less useful information because it is more confusing. In a scientific sense, the more numbers a subjective rating system has, the less “inter-rater reliability” that system has. The simplest subjective scale has only two scores, “None (zero)” and “Some (one),” as in “Do you have pain or not?” The subjective scale perhaps used most often in daily life (Like when you go to a Thai restaurant and are asked how hot you want your food to be) is a four score scale: None, Mild, Medium, Severe. The Visual Analogue score is a 6 point scale. CIWA-Ar uses 8 points. And the 10-Point JCAHO Pain Scale uses 11 points (zero plus one through ten). Is the 10-Point JCAHO scale more accurate than a simple “mild-moderate-severe” system? Probably not. In fact, no “probably” about it. No.
Subjective scoring systems work better at evaluating changes over time than the initial severity of a symptom. If a patient says his pain is a “6,” I may not know exactly how that is different from a “7” or even a “4.” But later, when the same patient now rates his pain as a “5,” I am pretty confident that his pain has decreased, at least by a little.
Subjective scoring systems only work if the patient understands and is cooperative with the process. Al helps the patient to understand the process with his excellent “anchoring” technique (which I will be adopting, by the way). But the system still will not work if the patient always, no matter what, says “my pain is a 10.” That is the main problem I run into in my jails; deciding when patients are exaggerating their symptoms. For example, if a patient complains of “severe” constipation, what weight do I give to their use of the word “severe?”
There are two types of subjectivity in scoring, the patient’s and ours. The patient is subjective when rating her own pain or depression or whatever. Then we clinicians make our own subjective assessments. How sick does the patient look? Often, the two assessments do not coincide, as when the patient rates his abdominal pain as a ten while munching on Cheetos and looking bored. If I do not trust the patient’s own subjective assessment, sometimes I must substitute my own clinical judgment.
Scoring systems for pain perform worse for chronic pain than for acute pain. For chronic pain, a more useful assessment tool is to evaluate how the chronic pain affects Activities of Daily Living (ADLs). Is the pain too debilitating to hold a job? Play golf? Go to the store? Walk? ADLs are usually much easier to assess in a correctional facility than in the outside world. You can go down to housing and watch the patient. How easily does the patient sit, stand, walk? Does the patient go to recreation? Sit for long periods of time playing cards or watching TV? This sort of assessment is very useful for gauging the impact of chronic pain.
I recently participated in a Webinar entitled “Managing Alcohol Withdrawal in the Correctional Setting.” During the question and answer section of the Webinar, a question was posed about how to manage the patient withdrawing from both alcohol and heroin at the same time. I have been thinking about this question since. In all my years of practice in correctional settings, I personally have never seen a patient who was simultaneously withdrawing from both alcohol and narcotics. Is such a thing even possible?
After thinking about it, I have decided that this question this question has two answers: a theoretical answer and a practical answer. The theoretical answer first:
Theoretically, if a patient was truly suffering from both alcohol withdrawal and heroin withdrawal at the same time, our primary concern would be alcohol withdrawal rather than heroin withdrawal. The reason for this is that patients die from alcohol withdrawal; it is a potentially lethal problem. Heroin withdrawal, on the other hand, can be a serious medical problem, but does not tend to be lethal. I was an emergency physician before I came to corrections, and this principle was drilled into us over and over–you deal with the life threatening concern first. Continue reading →
Delirious or psychotic? Sid Hamberlin, Jail Commander, Bonneville County Jail
In my career in corrections, I have seen 4 or 5 cases in which a patient was thought to be acutely psychotic, but actually was suffering from delirium. A typical case would present like this: Deputies report that Mr. Jones is acting strangely. He is talking to the wall of his cell and seems to be attempting to turn on a TV that isn’t there. He has been in jail for 5 days and was acting normally yesterday. Mr. Jones has a vague history of mental illness (he is on citalopram for depression) and so the deputies call mental health. Mr. Jones is not thought to be a danger to self or others, so is seen by the jail psychiatrist the next day. The psychiatrist notes a heart rate of 150, sweating and disorientation and diagnoses not psychosis but acute alcoholic Delirium Tremens (DTs).
Just to review, the term “delirium” refers to a syndrome of disorientation, confusion and often hallucinations caused by a specific disease process. For example, people who become septic from serious infections can become delirious. Pesticide exposure and overdose of many street drugs like “meth” and Ecstasy can cause delirium. Probably the most common cause of delirium in jails is the delirium of alcohol withdrawal, called “Delirium Tremens” or DTs.
Missing this diagnosis is very important since alcoholic Delirium Tremens is a life threatening condition. Some references put the mortality of untreated DTs as high as 30%. Were this patient to die because we missed his Delirium Tremens, well, it doesn’t look good on a resume.
So how did it happen that this life threatening condition was not recognized? As is often the case, several things went wrong here. First, Mr. Jones adamantly denied any history of alcohol abuse or previous withdrawal at booking and so was not placed under observation for withdrawal. He probably showed the typical early signs of withdrawal like hand tremors and sleeplessness but since he was in the dorm with a lot of other inmates, nobody noticed. Finally, and most critically, when he did begin showing signs of delirium, it was mistaken for psychosis. Nobody thought of alcohol withdrawal because Mr. Jones just didn’t fit the pattern we normally think of for alcohol withdrawal. He was acting crazy, so was thought to be crazy, not sick.
How To Tell Delirium from Psychosis (It’s Usually Easy)