March is Brain Injury Awareness Month

The CDC has declared March “Brain Injury Awareness Month”.  Traumatic Brain Injury (TBI) and its effects are common in the inmate population. Although an estimated 2% of the general population has sustained a TBI with continuing disability, a meta analysis of studies in the inmate population indicates a prevalence of over 60% .

This condition can be caused by assault, falls, motor vehicle crashes and military duty blasts. This means that high numbers of our patient population who have been victims of physical abuse or part of a violent lifestyle are prone to this condition.
TBI can lead to depression, anxiety, anger issues, and substance abuse. It can also predispose to seizure disorders, Alzheimer’s, and Parkinson’s diseases.
The long-term effects of TBI are memory problems, inability to focus, and poor impulse control. Inmates with this condition may respond in anger, aggression or verbal disrespect to cover for their deficits.

This means that our patients with TBI often show these behaviors:

• Act out in anger or irritation

• Forget rules of prohibited conduct

• Not remembering where they should be or by when

• Forgetting that they cannot go into certain areas

• Increased behavioral infractions

Watch for these signs of TBI in your patient population:

• Memory deficits

• Pain and headache

• Difficulty concentrating

TBI treatment focuses on symptom management and compensation for cognitive deficits. A careful intake history is an important first step to diagnosing TBI and managing symptoms. The CDC recommends that special attention be given to impulsive behaviors, violence potential, sexual behavior and suicide risk if the inmate is depressed.

Does your facility monitor TBI in the patient population? Tell us about your efforts in the comment section of this post.

Photo Credit: © drx – Fotolia.com

When Prison is an End-of-Life Sentence: Hospice in Corrections

Correctional nurses provide end-of-life care in this video documentary by Edgar Barens filmed in Iowa State Penitentiary

Terminal illness is an increasing possibility as inmate’s age and remains in custody. This can be a time of great sorrow, loneliness, suspicion, pain, and suffering for prisoners. They may have great fear of dying alone, in pain and without support. Every correctional facility will inevitably have an inmate who is diagnosed with a terminal condition. Are you prepared to provide the care needed for a good death in your facility?

There are several reasons why an inmate may live out their final days behind bars. It may be unsafe to release the inmate, even in their physically weakened state. Depending on community resources, it may be more appropriate to provide care in the correctional facility. In addition, the inmate may actually desire to remain at the facility because they have a support system or family close by.

People with life-limiting or terminal illnesses suffer not only from the illness itself but from loss of function, diminished control of their body, and loneliness as others around them go on with life. A prisoner suffers these losses but also experiences the loss of family, the freedom to determine their surroundings and schedule, as well as their individuality. The losses associated with incarceration magnify the suffering of an inmate patient with life-limiting illness.

According to the National Hospice and Palliative Care Organization, 75 prisons and jails in 41 states have a form of hospice program available to dying inmates. When the first programs started in prisons there were no standards for delivery of hospice services in correctional settings. Many programs now involve fellow inmates in peer-support roles that benefit both the dying inmate and the care provider.  Correctional nurses have an opportunity to profoundly affect the outcome of terminal illness and assist inmates to have a ‘good death’ even while incarcerated.

Do you have a hospice program at your facility? How do you manage dying inmates?

 

Correctional Nursing Alert: Ectopic Pregnancy

A young woman in custody at a large urban jail has continuing abdominal pain over a 14 hour period. She is found unresponsive in her cell and rushed to the hospital where she is pronounced dead on arrival. Autopsy reveals a ruptured ectopic pregnancy. Was this death avoidable?

Ectopic pregnancy, where a fertilized ovum implants somewhere outside the uterus, is an emergency event every correctional nurse should consider when confronted with abdominal pain in a female inmate of reproductive age. Indeed, this condition is particularly common among women with a history of genital infections or infertility. Smoking also increases risk. Therefore, the female inmate population is at increased risk for ectopic pregnancy.

 

Potential causes of acute pelvic pain are

  • Appendicitis
  • Ectopic Pregnancy
  • Endometriosis
  • Ovarian Cyst or Torsion
  • Pelvic Inflammatory Disease

 

Assessment Findings

Abdomenal pain caused by ectopic pregnancy can include vaginal bleeding. If pregnancy status is unknown, obtain a urine pregnancy test while contacting the physician. Patients with this condition can become unstable quickly. If a tubal rupture takes place, the pain will intensify and signs of shock such as low blood pressure and rapid thread pulse will be evident. Intraperitoneal hemorrhage can cause referred pain to the shoulder area and a very tender abdomen.

Nursing Actions

This is a medical emergency requiring fast action and immediate transport to acute care. Initiate emergency protocols which can include establishing an intravenous access and fluid loading.  Seek immediate medical evaluation for any potentially pregnant patient with unexplained abdominal pain. Ruptured ectopic pregnancies is a leading cause of maternal mortality in the first trimester resulting in 10-15% of all maternal deaths. Shock and death can follow quickly and immediate stabilization and transport to emergency treatment is necessary.

 

Have you had an experience with an ectopic pregnancy in a jail or prison setting? Tell us your story in the comments section of this post.

 

 

End of Life Care

Many states and counties are reeling from the increased expenses to continue providing healthcare to an aging inmate population. As the average age of US inmates increases, chronic disease and cancers escalate.

In an earlier post I talked about the basics of the aging inmate population. News articles pop up almost weekly about state correctional systems struggling with rising health care costs due to elder inmates and chronic disease.

A growing segment of the aging inmate population is those with cancer and other terminal illnesses requiring specialized care. Recently I spoke with Susan Loeb, PhD, RN, a nurse researcher implementing NINR granted funded research on end of life care in the PA Prison System [Correctional Nursing Today Radio Show]. Her research will lead to a toolkit for facilities to implement to develop a hospice program. It has been reported that at least 70 correctional facilities in the US have some type of hospice program with over ½ of them including inmate caregiver programs. Some facilities are partnering with community hospice services to provide needed staff education and specialty resources. Those with inmate caregiver programs have seen a positive impact on the attitudes and culture of both the inmate and custody community. An independent film was created following 3 dying inmates at the Kansas State Penitentiary. Edgar Berans, film producer, sites multiple positive outcomes of the program in a recent radio interview.

Some progressive correctional systems such as Washington State and California have already created assisted-living and long-term care facilities within their prison systems to accommodate these needs. Elderly inmates can fall victim to predatory younger inmates and require equipment such as wheelchairs and canes difficult to incorporate into a standard correctional system. Equipment of this type can be used as weapons if not properly managed.

Elder inmates also require environmental adaptations not usual in the correctional setting. They are unable to climb to top bunks and can become rattled or agitated by noise stress in prison barracks. Disabled inmates are challenged by stair or are unable to stand for long periods in the various lines that are a normal part of prison life.

How is your correctional system handling inmates at the end of life? Weigh in using the comment section of this post.

Needs of Prisoners with Cancer

Question Mark

What Are the Unique Needs of Prisoners With Cancer?

[By Mark Vrabel, MLS, AHIP, ELS, ONS Information Resources Supervisor]

Accreditation organizations such as the National Commission on Correctional Health Care (NCCHC) provide specialty standards and guidance for improving the quality of health care in jails, prisons, and juvenile confinement facilities. Lorry Schoenly, PhD, RN, CCHP, has been a nurse for 25 years and is on the national taskforce working to develop a correctional nursing certification (CCHP–RN) with NCCHC. Her Web presence at www.correctionalnurse.net provides a forum to interpret correctional health care to the public and healthcare community; I asked her about her experience as a correctional nurse and, more specifically, about information on inmates with cancer, and here is her response.

Correctional nurses must be adept at a variety of nursing specialties to accommodate the various medical needs of the inmate population. Prisons and jails are encouraged to perform common screenings for major cancers during the medical intake process. The inmate patient population generally has not taken advantage of regular medical care, and correctional medical services are often their first contact with organized medicine. Cancers are found that are well progressed due to a lack of regular medical screening.

Most state prison systems accommodate to some level the needs of inmates with cancer. Larger states have prison hospitals with hospice units. County jails are more challenging because they have fewer resources and the short stays allow only for emergency treatments. Some programs permit fellow inmates to provide nonmedical comfort care to hospice patients after appropriate training, such as the Connecticut Department of Correction Hospice and Palliative Care Program Inmate Volunteer Program. These programs can be a very humanizing activity in a very dehumanizing environment. Penn State University was recently awarded a National Institutes of Nursing Research grant to study end-of-life care in the Pennsylvania prison system. This will help give greater attention to patients with cancer in the later stages of their condition. The National Prison Hospice Association is a useful resource for obtaining additional information on hospice and end-of-life care in the correctional setting.

Mark Vrabel Mark Vrabel, MLS, AHIP, ELS, is the information resources supervisor for the Oncology Nursing Society. He replies to any and all questions sent to library@ons.org or clinical@ons.org (indirectly, sometimes assisting the nurses who handle this Clinical Questions service), and you can ask him questions by following him on Twitter at www.twitter.com/ONSmark. Read more articles by Mark Vrabel

Used with permission from ONS Connect: The official magazine of the Oncology Nursing Society

Transgender Inmates: He Said, She Said

THE SITUATION: You’re working medical screening for new detainees at a large urban jail. Your next case arrives for assessment with make-up and bright female clothing, although you also see male-pattern facial hair and muscle structure. What do you do?

Transgender individuals are over-represented in the inmate population. If you work in corrections, you are likely to come face-to-face with your attitudes and emotions about these individuals. Nursing ethical principles require those of us in the profession to provide nursing care with concern and respect for human dignity, no matter the life choices the individual has made.

Transgenders (also called trans or cross-genders) are individuals with an incongruity between their felt gender and their anatomic gender. The majority are male and can have a DSMIV diagnosis of gender identity disorder (GID). Your inmate-patient may be in the midst of hormonal therapy or have partial or complete sex reassignment surgery (SRS).

Conversation

Your first concern is how to address the person. Do you use the term ‘He’ or ‘She’? Though it may seem trivial, your sensitivity in this area will establish needed repoire. Often you can avoid using gender terms or you can clearly see which term to use. For example, the individual above is likely to desire to be referred to as ‘she’, especially if the clothing involves a dress or skirt. When in doubt, your best option is to ask the individual how they would like to be addressed. Let them be in control of this small issue – control of so much else is gone. Attempt to be as matter-of-fact and non-judgmental as possible in all interactions.

Destination

Unless your system has special facilities for the transgender inmate, such as the new 30-bed transgender Italian prison, administration will need policies in place to determine housing designation. This is a vulnerable population requiring some type of protective housing.  The nature of the condition predisposes the inmate to a higher potential of assault or in-custody violence. In addition, those with GID are more likely to be depressed, suicidal or self-injurers. Keep this in mind when assessing these inmates for any health conditions.

Change Management

What if the person is in the midst of hormonal therapy or SRS? What responsibilities are there for maintaining or continuing escalation of therapy? Policies regarding transgender treatment differ among state and county systems. Investigate the policy at your facility before you need to use it. Discuss the situation with your manager and medical director.

In  a recent survey of correction system policies about transgender treatment, the majority of responding facilities had policies for the continuation of hormonal therapy, at least at the current level. Abrupt discontinuation of hormonal therapy can lead to physical and psychological side effects and should be avoided. Many facilities will use a ‘freeze-frame’ approach which continues the current therapy but does not escalate or advance the gender-change process.

Autocastration – Medical Emergency

Be aware that disturbed individuals may resort to autocastration or autopenectomy to reduce testosterone levels. The elasticity of the testicular arteries allows them to retract into the perineum making it very difficult to staunch the flow. Emergency transport, critical care and blood transfusion may be necessary.

More Resources on Transgender Treatment

Lock Up Doc on KevinMD

Transgender Guidelines from NCCHC

How Should Agencies Manage Transgender Inmates?

Pepper Spray: In Your Face

THE SITUATION: A call just came in from cell block D. They are enroute with an inmate for evaluation after being subdued with several applications of pepper spray following an aggressive incident. Two officers also sustained minor injuries during the take-down. What should the nurse prepare to do in the pepper spray evaluation?

Pepper spray is a popular option to subdue violent or psychotic inmates when other de-escalation methods fail. It is preferred over options of lethal force in most correctional settings. A spray of concentrated capsaicin oil incapacitates most individuals due to the noxious odor and burning eyes and skin. Concentrations of the pepper oil can range from 5-15% depending on the product used. Potential health impact is directly correlated to the strength of concentration. If possible, obtain information about the standard products used in your facility to assist with your post-spray assessment.

The effects of pepper spray are related to skin and eye irritation, as well as neurogenic inflammation. When pepper spray comes in contact with eyes, nose and mucous membrane it causes involuntary eye closure and a sensation of shortness of breath. These conditions provide greater chance of apprehension and incapacitation. Officers should use the minimum amount necessary to contain the situation, however, sometimes a great deal of spray is necessary and your patient may arrive having been immersed in oil.

Take Action

Use a well-ventilated exam room to assist in eliminating respiratory effects of pepper spray. Focus on these areas when performing your evaluation and determining follow-up treatment or observation.

  • Respiratory

There is some indication that pepper spray is particularly hazardous to those with asthma or a current respiratory infection. Check the medical record (if available) for past history and complete a thorough respiratory evaluation. Capsaicin oil causes wheezing, dry cough, shortness of breath and gagging.

  • Cardiac

As some have reported acute hypertension initiated by extreme pepper spray use, a vital sign check and cardiac history should also be undertaken. Symptoms usually clear in the first hour after the incident.

  • Skin Irritation

Skin irritation can be intense and include burning, tingling, redness and occasional blistering. Remove any remaining vestige of irritant by having the patient wash exposed skin with soap and water. Change any soaked clothing. Irritation should clear in 30-60 minutes. Cool water or an ice pack can help to relieve a burning sensation.

  • Eye Irritation

Redness, swelling, extreme pain, tearing and conjunctival inflammation are experienced with direct contact of the oil on eye surfaces. Eye exposure should be treated as with any other chemical eye contact – flush with water (or normal saline) for at least 15 minutes. Your medical unit should have an eye station for this purpose. Corneal abrasion can also occur, especially if contact lenses are in place. If corneal abrasion is possible, slit lamp evaluation may be necessary.

Caution Warranted

Although the majority of your patients will recover from pepper spray incidents quickly and without need of treatment, several in-custody deaths have been attributed to the chemical. A focused nursing assessment will reveal any issues of concern. Cardiac or respiratory involvement may indicate a brief stay in your infirmary for closer observation before discharge to general population.

Read More

Effectiveness and Safety of Pepper Spray, Dept of Justice

Medical Aspects of Less Lethal Weapons

Photo: © Stocksnapper – Fotolia.com

Alcohol Withdrawal: Jail Nurse Alert

If you work in a jail, it is in your best interest to become an expert at assessing and intervening in alcohol withdrawal syndrome (AWS). It is the most dangerous type of substance withdrawal and the most prevalent. The recently published Behind Bars II: Substance Abuse and America’s Prison Population identifies 85% of all inmates have substance involvement. Over half of American inmates are incarcerated due in some way to alcohol. Once behind bars, withdrawal begins with potential dangers.

Withdrawal from alcohol causes increased excitability in the nervous system leading to nausea, vomiting, sweating, shakiness, agitation and anxiety.  A medical emergency can develop when withdrawal leads to  delirium tremens (DTs) involving hallucinations, confusion, disorientation, and generalized seizures. Autonomic hyperreactivity can progress to hypertension, tachycardia, hyperthermia, tachypnea and tremors.

Tag, You’re It

A thorough history and assessment at intake can identify inmates who need close watching during the first few days of incarceration. Be sure your intake questioning gathers information about alcohol history and timing of last drink. Ask about any previous withdrawal episodes and if they resulted in hallucinations or hospital visits. Although the mild to moderate withdrawal symptoms will peak and wane in the first 2 days, DT’s occur around 48-72 hours after the last drink. Untreated DT’s can lead to cardiovascular collapse.

The most tested assessment tool for the identification of persons at risk for alcohol withdrawal is the CIWA-AR Scale. It uses a numbering system to objectively determine severity of withdrawal and can be used over time to document the course of AWS for an individual inmate. Experts recommend twice daily CIWA-AR assessment for those determined to be vulnerable.

Hydrate Pronto

High on the list of non-pharmacologic interventions for AWS is hydration. Alcoholics are often dehydrated, which increases nervous system excitability. Encourage withdrawing inmates to increased fluids by mouth. Some facilities provide electrolyte replacement fluids, such as Gatorade or other sports drink  to withdrawing inmates, as alcohol-dependent individuals are often electrolyte depleted.

Food for Thought

The chronic drinker is likely to be glycogen-depleted and malnourished. These conditions enhance AWS symptoms. Get these folks into the meal system pronto. Encourage nutritious eating to replace stores. Good choices to have available are milk, sandwiches and peanut butter crackers.

Get ‘em Mellow

Reducing nervous system excitability will decrease chances of life-threatening DTs. Providing a short-term (5 day) taper of Librium, valium or other barbiturate will decrease  the chances for respiratory and cardiovascular collapse. Of course, a physician order is needed for this intervention. Examples of pharmacologic treatment can be found in many sources, including the Merck Manual. A standard protocol for barbiturate treatment with stock medication available can smooth the initiation of effective treatment on hectic, high-load weekend nights. Encourage your facility to have a treatment system set up for AWS.

Don’t be Afraid to Package and Ship

If you are unable to forestall seizures, hallucinations or hemodynamic instability, arrange for emergency transport to the nearest emergency room. Jails are not equipped to monitor and manage life-threatening situations. Pack them up and send them to the next level of care.

With the patient population entering your jail every day, you need to be ever vigilant for potential alcohol withdrawal. With solid assessment tool, close observation and early intervention,  you will be ready before trouble strikes.

What do you do at your facility to recognize and treat alcohol withdrawal? Share your thoughts in the comments section of this post.

Exertional Rhabdomyolysis: Inmate Bodybuilder Disaster

The majority of our inmate patients are still fairly young. Many of the youthful inmate population spend available time in sports and bodybuilding activities. These individuals are prone to contracting exertional rhabdomyolysis (rhabdo). Correctional nurses need to be alert to the potential and respond effectively to stave off a disastrous outcome.

What Causes Rhabdo?

Rhabdo is the breakdown of muscle tissue causing an outpouring of intercellular contents including myoglobin, potassium, and creatine kinase (CK). These three elements cause the life-threatening effects of the condition. Non-traumatic rhabdo can be caused by severe over-exercise, major drug ingestion, or as a result of statin use. Many corrections-related incidents of rhabdo appear in the literature including 110 knee-bends performed as a part of an inmate hazing event, narcotic overdose and intravenous drug use.

Silent Symptoms

Rhabdo can start innocuously and may be overlooked as delayed onset muscle soreness (DOMS) from over-exertion. However, if the overly sore muscles are accompanied by brown (coca-cola) urine or urine irregularities such as nocturia or anuria, beware. Further assessment is warranted.

Nursing Actions

A good history and assessment is necessary, including any unusual activities over the last 48 hours and a medication review. Many of our patient population are now on statins, which can complicate exertional rhabdo. If Rhabdo is suspected, labs for CK, potassium, and myoglobin should be drawn while monitoring urine output and cardiac rhythm. Under medical direction, fluids should be administered to assist the body to flush out the muscle breakdown byproducts. If not caught early enough, renal dialysis and/or cardiac interventions may be necessary.

Patient and Officer Education

One of the best nursing interventions for rhabdomyolysis is patient and officer education. Inmate bodybuilders should be aware that brown urine is a bad sign that should lead to a medical visit request. Officers should understand the adverse effects of hazing activities that might be a part of a particular inmate culture. Our aggressive and macho patient population can fall prey to competitive weightlifting challenges that go beyond rational sense, requiring intervention. Prevention or early treatment of rhabdo can avoid renal failure and life-threatening arrhythmias.

With awareness, education and vigilance, correctional nurses can reduce the chances of life-threatening results of rhabdomyolysis.

Have you experienced a rhabdo incident at your facility? Share your experience in the comments section of this post.

Excited Delirium – Out of Control!

A medical emergency is called in the booking area of a large urban jail. The inmate has ripped off his clothing and is racing about screaming profanities. Custody officers finally subdue him with tazers and have him on the floor securing restraints when he stops breathing. Standard emergency treatment is provided without result. The inmate is pronounced dead on arrival to the local hospital. What just happened?

Excited Delirium (ED) is a rare but deadly condition that can confront nurses working in corrections – particularly jails. Experts differ on the cause or even existence of the condition. However, evidence is mounting in favor of the diagnosis for a variety of unexpected deaths after situations similar to the one described above.

Causes of ED

A prevailing theory is that ED is caused by overstimulation of the brain by dopamine. Cocaine, narcotics or extreme stress can cause an increase in dopamine release. Another biomarker under study is the release of heat shock proteins that leads to problems with body heat. The person’s body temperature rises rapidly without regulation. This combination overpowers the heart and respiratory systems leading to sudden death.

What does ED Look Like?

The challenge of excited delirium in the corrections environment is to quickly identify that we have a medical condition as well as a behavioral issue that needs controlled and treated. An individual in the throes of ED will seem superhumanly strong and intensely hysterical, resisting all attempts at restraint. Often they are pulling off clothing to reduce the overheating. They often seem oblivious to pain and have little response to tazors or pepper spray.

What’s a Nurse to Do?

Correctional medical experts such at Todd Wilcox, MD, Medical Director of Salt Lake County Jail, recommends maximum efforts to subdue the individual to allow immediate medical intervention. This would not be a time for officers to slowly escalate force tactics. Once subdued, benzodiazepines to reduce the agitation is the first treatment of choice.  However, corrections nurses should focus on activities to speed transport to an acute care facility able to effectively manage the condition. Temperature regulation along with oximetry and cardiac monitoring are available in that setting.

Have you had an experience with excited delirium? Share it in the comments section for this post.

Learn more about Excited Delirium

http://www.exciteddelirium.org/  

EMS Post: Cocaine, Excited Delirium and Sudden Unexpected Death

Excited delirium: Considerations of selected medical and psychiatric issues