Tag Archives: evidence based medicine

Oral Testing of Reported Penicillin Allergies?

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Penicillin is miraculous.  It was discovered in 1928 by Alexander Fleming (founding the modern era of antibiotic medicine) and is still the most common antibiotic prescribed in my jails.  The dentist and I use Penicillin VK as our preferred initial agent for dental infections.  I prescribe PCN VK, as well, for strep throats.  I use amoxicillin occasionally for sinus infections and UTIs and even amoxicillin/clavulanate (Augmentin) occasionally. 

Because penicillin is so useful (and inexpensive), I hate to hear the words “I’m allergic to penicillin.” If a patient with a dental infection can’t take penicillin, for example, the dentist commonly prescribes clindamycin, which is expensive, a pain to administer three times a day and has potentially bad side effects.  I have seen more than one patient who developed C. difficile after getting a broad-spectrum antibiotic because of a reported penicillin allergy–probably unnecessarily!

This problem is pretty common since about 10% of the adult population will report a penicillin allergy.  However, research has shown that, when tested, more than 90-95% of patients who state that they have a penicillin allergy really do not. These patients can be harmed by giving them an inferior antibiotic more likely to cause them harm than plain old penicillin.

The test most commonly used to gauge true allergic status is Penicillin Skin Testing (PST). No jail or prison that I know of does skin prick tests.  We also don’t refer patients reporting penicillin allergy to an allergist for testing.  We just groan and prescribe an inferior antibiotic. 

However, this could potentially change based on research published this year on the safety and efficacy of “Direct Challenge” penicillin allergy testing.  Direct challenge means giving a low-risk (this is important) patient an oral dose of whatever penicillin you want to prescribe and observing them for an hour for an allergic reaction. This has been done in studies and has been reported to be safe and effective.

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When Should Medical Clearance Be Done? PLUS Sample Guideline!

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When arresting officers arrive with their charges at a certain large urban jail, the first person they see when they come through the doors is a nurse. The nurse quickly evaluates the arrested person to determine whether a medical clearance is needed before the person can be booked. If a clearance is needed, the arresting officer has to transport the prisoner to a local ER and then return with the medical clearance in hand.

One evening (so the story goes), an arresting officer arrives at the jail bodily dragging a prisoner through the pre-book door by the backseat of his pants and coat. “This guy’s an a**hole,” the officer says. “He won’t do anything I ask. He just ignores me.” He then dumps the prisoner on the floor. The nurse kneels down by the prisoner briefly, looks up and says, “That’s because he’s dead!”

Medical clearances are a hugely important and often neglected part of the jail medical process.

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Do You Understand the Requirements for Multiple DEA Licenses?

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I have found that many correctional practitioners, especially in jails, do not understand the license requirements of the federal Drug Enforcement Agency (DEA) and, as a result, do not have all of the DEA licenses that they are legally obligated to obtain. 

Take, for example, a correctional physician that we will call Dr. K who is employed full time a a large urban jail and has had a DEA license for that jail for many years.  On the side, she also provides medical services to three other smaller jails, where she does clinics once a week. The question is whether her one DEA license covers her activities at the other jails.  Dr. K has always thought that she only needs one DEA license—just like she only needs one Driver’s License—and it will cover all of her activities. 

But the real answer is, “No,” Dr. K is not in compliance with DEA regulations.

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Constipation Plus Sample Guideline

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Today’s post is a repost of an article I wrote previously about Constipation. Concurrent with this article, I have added a Sample Guideline on Constipation to the Guideline Section of JailMedicine (found here).

I have decided after many years of dealing with complaints of constipation both in the ER and in correctional facilities that bowel health is the last taboo subject.  We all received “The Talk” (about sex and reproductive health) when we were adolescents.  But nobody seems to talk about how to have a proper bowel movement.  It is a subject that inevitably causes giggling and uncomfortable laughter.  It is not spoken of in polite society.  As a result, many people do not understand how their bowels work.  I have found this to be a big problem in the jails I work in.  Inmates complain of constipation when they are not really constipated.  They are bowel-fixated when there is no reason for them to be.  Often, they need education more than they need laxatives. To this end, I want to discuss several essential factors relating to understanding and treating constipation that may help make your correctional medicine practice a little easier.

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Skeletal Muscle Relaxant Guideline

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Today’s post is a repost of an article I wrote previously about Skeletal Muscle Relaxants (SMRs). Concurrent with this article, I have added a Sample Guideline on prescribing Skeletal Muscle Relaxants to the Guideline Section of JailMedicine.

Personally, I think that skeletal muscle relaxers like cyclobenzaprine, methocarbamol and chlorzoxazone are over prescribed for acute and chronic musculoskeletal pain, both in the outside world but especially in corrections. The main reason for this, I think, is that prescribers misunderstand what muscle relaxers do. Contrary to their name, muscle relaxers do not relax muscles, at least as they are commonly prescribed. Muscle relaxers are sedatives, pure and simple, and should be prescribed with that fact in mind. Instead of telling patients (and ourselves) that “I am prescribing a muscle relaxer for you,” in the interest of full disclosure, we should be saying “I am prescribing a sedative for you.”

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The Root Cause of Jeffrey Epstein’s Suicide

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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.

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The Art Of Meeting New Patients in a Jail

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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:

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Comfort Items: Why Not?

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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.

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Reader Question: Don’t Be the Decider

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I work at a prison and your blog has been such a resource for our unique niche of medicine. There’s nothing like practicing “behind the walls!” . . .
Recently I’ve been incorporating more conversations about functionality and short-term/long-term goals and visits are mostly positive. However, there are the difficult patients . . . wanting to bargain “well if you’re not going to do anything, can I have an extra mat?” Or “Can I have a bottom floor restriction?” “Transfer me then!” “Give me insoles.” …and other requests like this. How do you recommend I come to an agreement with these patients that are difficult to have conversations with? . . . If by the end of the appointment we do not come to some sort of agreement, they end up right back in sick call with the same complaint. Then the cycle repeats. KR

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Transforming Our Approach to Chronic Pain

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One of the most fearful and frustrating events in my correctional medicine world used to be when a new chronic pain patient would arrive in my clinic.  A typical patient would be a “Ralph,” a middle-aged man who has had chronic back pain for many years.  Ralph has had a couple of back surgeries, steroid injections and more than one kind of stimulator, none of which has been effective.  He arrived at the jail taking a long list of sedating medications such as muscle relaxers, gabapentin, and sleeping aids plus, of course, big opioids.  In addition, Ralph has alcohol abuse issues.  The reason he is in jail is a felony DUI charge.  Now he is in my medical clinic, looking expectantly at me.  How am I going to fix his pain problem? 

The answer, of course, is that I am not.  I am not that smart.  He has already seen lots of doctors, including pain specialists and surgeons, who have tried almost everything that can be tried and they have not fixed his chronic pain problem.  I’m not going to be able to, either.  In my opinion, the most common and serious mistake made in the treatment of chronic pain in corrections is when we imply that we can eliminate chronic pain. 

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