Managing Critical Dilemmas in Correctional Care

By Lynn Sander, MD

Posted on January 14, 2009 – Back by popular demand, Joseph Paris, MD, moderated an interactive session on complicated clinical situations at the SCP annual conference on October 19. Dr. Paris pointed out that working in the correctional setting is inherently challenging for several reasons, including practicing medicine in a nonmedical environment. Frequently our patients are not medically sophisticated and are poor historians. This is compounded by the lack of current medical records. This population has a high incidence of mental illness and substance abuse, many have a risk-taking lifestyle, and most come from a medically underserved population with a lack of previous health care. This combination of factors leads to situations usually not found in community medicine.

Several cases were presented and then the audience was asked for suggestions on how to manage the situation. In most cases, there is no right or wrong answer, but information from experienced colleagues regarding how similar cases were handled is often helpful to those new to the field. It is hoped that a recap of the discussions will prove interesting and useful to our readers.

Case 1
As the prison’s medical director, you are called down to the maximum security area. Upon arrival, you see five officers holding down a long-term inmate with a history of explosive and vicious behavior. The lieutenant in charge says, “Doc, give him a shot to make it easier to place him in the restraint chair so no one is hurt.” What do you do?

Discussion
First, one must talk to the patient to determine if he is psychotic or if this is behavioral. Treatment should be based upon this determination. Include in your differential agitated delirium, which requires immediate medical treatment. You also should inquire why the officers want to restrain the patient, and if it is a punitive action. It is important to know your state’s laws. Although most states do not allow involuntary medication except if the patient is an imminent danger to himself or others, some states do allow involuntary medical for behavioral control. One must remember that the restraint chair can be dangerous and may lead to patient morbidity and mortality. Anytime you are forced to use physical restraint, you are in a risk situation. Other suggestions given were: try to talk the patient down, increase the number of officers present and a small number present would give the shot to allow for transport. Lastly, it is crucial that your facility develop policies and procedures for this situation.

Case 2
As the jail’s medical director, you receive a call from the night nurse at 2:00 AM about a new intake in the “drunk tank” (used for observing intakes with mild intoxication/withdrawal prior to placement). She states that she has a bad feeling about a slightly drowsy new intake in the tank. She continues, “This inmate was sutured at the ER just prior to intake, and the ER gets mad if we send back an inmate that they already evaluated” What would you do next?

Discussion
Simultaneously, most of the audience shouted, “Send him back!” It was then pointed out that you should get more information from the nurse regarding objective findings such as vital signs, mental status, and the injury that was sutured. Even if this did not reveal significant findings, your decision would most likely be the same. If the nurse is experienced and one who you trust, you will go with her sense of the patient. If you were less comfortable with the nurse, you would want to have further evaluation. Dr. Paris asked if you would go in to see the patient, but it was pointed out the time to get to the facility might be problematic if the patient needed more urgent intervention. And if further diagnostic testing were required, you would not be able to accomplish this at the jail. Dr. Paris also asked what you would do if security balked at transporting the patient back; however, both patient safety and NCCHC standards require that corrections must be convinced that the transport is necessary.

Case 3
You are the prison medical director. A 60-year-old, male smoker with whom you are familiar is readmitted to the prison. During his previous 2-year incarceration, he developed an abnormal chest x-ray and shortness of breath. He signed a refusal for bronchoscopy and biopsy, saying that “it was a done deal.” And so he was released without evaluation or treatment. You note he is short of breath at rest, and has abnormal liver function tests and anemia. What would you do next?

Discussion
The general consensus was that you approach the patient again about evaluation. If he refuses, you must take measures to assure that other inmates and staff are safe in case he has an infectious disease such as tuberculosis. It was also suggested to find a provider with whom the patient can develop a trusting therapeutic relationship. Also mentioned was bringing up the issue of compassionate release, in case this might motivate him to have a diagnosis.

If these discussions sound interesting to you, save October 18, 2009, for SCP’s annual conference in Orlando, FL.