FORUM
A Novel Approach to the Problem of Health Care in Jails Lawrence J. Guzzardi, MD* G. Richard Braen, MD* Lexington, Kentucky David P. Jones, MAt London, Kentucky
Guzzardi LJ, Braen GR, Jones DP: A novel approach to the problem of health care in jails. JACEP 8"377-379, September 1979.
health care defivery, jails
INTRODUCTION The 150,000 people confined in j a i l s in the U n i t e d S t a t e s 1 have u n i q u e h e a l t h problems a n d a s i g n i f i c a n t l y h i g h e r percentage of medical disease t h a n the g e n e r a l population. 2 T h e i r access to medical care is f r e q u e n t l y d e t e r m i n e d by the jailer, who m a y be more concerned about security and cost t h a n medical care. T y p i c a l l y , i n m a t e s come from t h e s a m e u n d e r e d u c a t e d , poor, e t h n i c m i n o r i t i e s t h a t h a v e g e n e r a l l y b e e n left out of the t r a d i t i o n a l medical care system in the U n i t e d States. I The m e d i a n l e n g t h of stay in j a i l s is seven days ~ m a k i n g c o n t i n u i n g care difficult. In r u r a l areas, which m a y a l r e a d y have a shortage of medical facilities, the provision of medical care in j a i l s to a t r a n s i e n t a n d socially u n d e s i r a b l e s e g m e n t of t h e p o p u l a t i o n is often given a low priority. In the l a r g e r m u n i c i p a l jails, t h e r e m a y be a p h y s i c i a n a v a i l a b l e to conduct d a i l y sick call and to supervise h e a l t h care d u r i n g week d a y "business hours." It is u n u s u a l for even the best equipped and most h u m a n e j a i l s to h a v e a p h y s i c i a n a v a i l a b l e for more t h a n 30 hours per week. 2 In s m a l l e r jails, there is g e n e r a l l y no medical care a v a i l a b l e on the p r e m i s e s and t h e sick i n m a t e m a y be escorted to a local physician's office or to a hospital e m e r g e n c y d e p a r t m e n t . 2 Since t h e i n m a t e cannot g e n e r a l l y s e e k out medical care on his own, he is at the mercy of the jailer. Therefore, the i n m a t e m a y be denied access to medical treatment. There exist, however, compelling legal a n d moral a r g u m e n t s for the provision of h e a l t h care in jails. I t m a y be cost effective to screen for tuberculosis, v e n e r e a l disease a n d h e p a t i t i s w i t h i n t h e i n m a t e population because of t h e high prevalence of these conditions. 3 The proscription of cruel a n d u n u s u a l p u n i s h m e n t in the U n i t e d S t a t e s Constitution h a s been i n t e r p r e t e d b y t h e S u p r e m e Court as a g u a r a n t e e of basic h e a l t h care for i n m a t e s . 4 F e d e r a l J u d g e F r a n k J o h n s o n ordered the f e d e r a l From the Division of Emergency Medicine, Universil~.;'of Kentucky Medical Center, Lexington, Kentucky,* and the Department of Human Resources, Commonwealth of Kentucky, London, Kentucky.1Address for reprints: Law[ence J. Guzzardi, MD, University of Kentucky Medical Center, Division of Emergency Medicine, Room H-152F, Lexington, Kentucky 40506.
8:9 (September) 1979
JACEP
377/63
supervision of A l a b a m a State Prisons because of the d e f i c i e n c i e s in b a s i c h u m a n needs. One of those human needs was medical care. Numerous civil lawsuits based upon improper medical care rendered to an inmate while in custody have been brought against jailers. The number of such lawsuits is increasing. A recent publication of the American Medical Association has established guidelines and standards for health care in jails. 5 One method of augmenting these guidelines is to improve the skills of jailers in recognizing and managing medical emergencies and common medical problems. J a i l e r s should be t a u g h t such basic information as signs and symptoms of appendicitis and myocardial infarction, the common sense management of seizures and gastroenteritis, and the r e c o g n i t i o n of h e p a t i t i s a n d t u b e r c u l o s i s . A t a minimum, jailers should be proficient in adult cardiopulmonary resuscitation (CPR). 5 Most of the medical information t h a t a j a i l e r should know is closely related to the field of emergency medicine. The logical provider and director of such a course of instruction for jailers is the department of emergency medicine that is already providing s o m e w h a t s i m i l a r t r a i n i n g for e m e r g e n c y medical technicians and paramedics. The Division of Emergency Medicine at the University of Kentucky in Lexington, Kentucky has developed a 30-hour course to teach jailers the basics in management of common medical emergencies and recognition of depression and psychiatric emergencies. In addition, attention is given to techniques for the prevention of communicable diseases. The course is divided into nine self-contained modules (Table). Each module consists of a 20-minute video tape prepared by a physician followed by 20 to 30 minutes of classroom instruction conducted by a professional educator associated with the Kentucky Department of Correction (Bureau of Training). Each student is given a comprehensive syllabus for future reference. The module on cardiopulmonary resuscitation is given by American H e a r t Association instructors and fulfills the requirements for a "Heartsaver" course. This section includes adult CPR and the abdominal thrust maneuver but not infant resuscitation. The course was first given in April 1978 at Eastern Kentucky University, a central site for the training of jailers in the Commonwealth of Kentucky. Almost all Kentucky jailers will have participated in this course by December 1980.
Table COURSE MODULES FOR JAILER HEALTH CARE INSTRUCTION
I. Infectious Disorders A. Prevention and recognition of hepatitis. B. Screening for recognition and symptoms of tuberculosis. C. Recognition of syphilis and gonorrhea. Screening tests. I1. Diabetes Mellitus, Epilepsy and Burns A. The hyper- and hypoglycemic syndromes. Diabetic medications including insulin. Urine testing. B. Treatment of seizures (first aid measures). Facts (vs. myths) about epilepsy. C. Types of burns. D. When to refer a burn to a physician. III. Circulatory Disorders ', A. Recognition of myocardial infarction and angina. B. Cerebrovascular accidents. C. Risk factors including hypertension. IV. Diarrhea, Vomiting, Appendicitis A. Recognition and first aid treatment of common disorders of GI tract. B. Signs and symptoms of appendicitis. VI. Screening Examination, Management of Medications A. Fundamentals of the intake examination. B. When to refer a patient to a physician. C. A rational plan for medication control and inventory in the small jail and large jail. D. How to give medications (including insulin). VII. Medical Records System A. Implementation of the Commonwealth of Kentucky Department of Human Resources Medical Records System. VIII, Psychiatric Problems A. Drug overdose. B. Drug withdrawal a. alcohol b, barbiturates c, tranquilizers C. Anxiety neurosis D. Suicidal risk E. Treatment of suicide attempts F. A plan for psychiatric referrals
DISCUSSION The developers of this course and the Kentucky D e p a r t m e n t of Corrections hoped to develop j a i l e r s who would function as knowledgeable laymen r a t h e r than as health paraprofessionals. With this in mind, instruction in such things as blood pressure determination, examination of throats or venipunctures was deliberately avoided. The jailer places himself and his institution at an additional legal risk once he begins to perform any medical fdnctions. In the litigious atmosphere of jails, questions of malpractice or misjudgment may be considerable. T h e j a i l e r could not be expected to learn enough medical information to adequately assess a large variety of medical conditions. Jailers who have completed this course in Kentucky do not view themselves as health care providers but 64/378
IX. Respiratory Disorders A. Emphysema and chronic obstructive lung disease. B. Risk factors. C. When to refer the dyspneic patient. D. Bronchitis and pneumonia. E. The obstructed airway. F. Demonstration and discussion of abdominal thrust maneuver.
JACEP
8:9 (September) 1979
primarily as policemen or custodians who have been enlightened in some aspects of medicine. The process of accrediting h e a l t h care s t a n d a r d s in jails h a s a l r e a d y begun. I m p r o v e m e n t in h e a l t h standards m a y soon become m a n d a t o r y because of recent court r u l i n g s a n d because of the growing public awareness of the health care problems in jails. Eradication of the medical deficiencies in j a i l s m u s t begin with the j a i l e r s and their education is a vital part of this process. We anticipate t h a t t r a i n i n g programs for jailers will soon be started in other states. The A m e r i c a n Medical Association has a c o m m i t m e n t to the t r a i n i n g of jailers and has collaborated in the preparation of a program of i n s t r u c t i o n3 that is even more ambitious than the program conducted at the U n i v e r s i t y of Kentucky. E m e r g e n c y physicians should be aware of this new t r e n d in health care b e h i n d j a i l walls because
8:9 (September) 1979
they m a y be asked to participate in the t r a i n i n g of jailers w i t h i n the c o m m u n i t y i n the future.
REFERENCES 1. Sourcebook of Criminal Justice Statistics, 1976. US Dept Justice, Law Enforcement Assistance Administration, National Criminal Justice Information Statistic Services 523-48 Characteristic and Distribution. 2. Medical Care in US Jails, A 1972 Survey. Chicago, American Medical Association, 1972. 3. King L, Geis G: Tuberculosis transmission in a large urban jail. J A M A 237:791-792, 1977. 4. Isele WP: Constitutional Issues of the Prisoner's Right to Health Care. Chicago, American Medical Association, 1976, pp 1-24. 5. Standards for the accreditation of medical care and health services in jails. Chicago, American Medical Association, 2PA 1961: 78:00243:8/78, 1978.
JACEP
379/65
A Novel Approach to the Problem of Health Care in Jails Lawrence J. Guzzardi, MD* G. Richard Braen, MD* Lexington, Kentucky David P. Jones, MAt London, Kentucky
Guzzardi LJ, Braen GR, Jones DP: A novel approach to the problem of health care in jails. JACEP 8"377-379, September 1979.
health care defivery, jails
INTRODUCTION The 150,000 people confined in j a i l s in the U n i t e d S t a t e s 1 have u n i q u e h e a l t h problems a n d a s i g n i f i c a n t l y h i g h e r percentage of medical disease t h a n the g e n e r a l population. 2 T h e i r access to medical care is f r e q u e n t l y d e t e r m i n e d by the jailer, who m a y be more concerned about security and cost t h a n medical care. T y p i c a l l y , i n m a t e s come from t h e s a m e u n d e r e d u c a t e d , poor, e t h n i c m i n o r i t i e s t h a t h a v e g e n e r a l l y b e e n left out of the t r a d i t i o n a l medical care system in the U n i t e d States. I The m e d i a n l e n g t h of stay in j a i l s is seven days ~ m a k i n g c o n t i n u i n g care difficult. In r u r a l areas, which m a y a l r e a d y have a shortage of medical facilities, the provision of medical care in j a i l s to a t r a n s i e n t a n d socially u n d e s i r a b l e s e g m e n t of t h e p o p u l a t i o n is often given a low priority. In the l a r g e r m u n i c i p a l jails, t h e r e m a y be a p h y s i c i a n a v a i l a b l e to conduct d a i l y sick call and to supervise h e a l t h care d u r i n g week d a y "business hours." It is u n u s u a l for even the best equipped and most h u m a n e j a i l s to h a v e a p h y s i c i a n a v a i l a b l e for more t h a n 30 hours per week. 2 In s m a l l e r jails, there is g e n e r a l l y no medical care a v a i l a b l e on the p r e m i s e s and t h e sick i n m a t e m a y be escorted to a local physician's office or to a hospital e m e r g e n c y d e p a r t m e n t . 2 Since t h e i n m a t e cannot g e n e r a l l y s e e k out medical care on his own, he is at the mercy of the jailer. Therefore, the i n m a t e m a y be denied access to medical treatment. There exist, however, compelling legal a n d moral a r g u m e n t s for the provision of h e a l t h care in jails. I t m a y be cost effective to screen for tuberculosis, v e n e r e a l disease a n d h e p a t i t i s w i t h i n t h e i n m a t e population because of t h e high prevalence of these conditions. 3 The proscription of cruel a n d u n u s u a l p u n i s h m e n t in the U n i t e d S t a t e s Constitution h a s been i n t e r p r e t e d b y t h e S u p r e m e Court as a g u a r a n t e e of basic h e a l t h care for i n m a t e s . 4 F e d e r a l J u d g e F r a n k J o h n s o n ordered the f e d e r a l From the Division of Emergency Medicine, Universil~.;'of Kentucky Medical Center, Lexington, Kentucky,* and the Department of Human Resources, Commonwealth of Kentucky, London, Kentucky.1Address for reprints: Law[ence J. Guzzardi, MD, University of Kentucky Medical Center, Division of Emergency Medicine, Room H-152F, Lexington, Kentucky 40506.
8:9 (September) 1979
JACEP
377/63
supervision of A l a b a m a State Prisons because of the d e f i c i e n c i e s in b a s i c h u m a n needs. One of those human needs was medical care. Numerous civil lawsuits based upon improper medical care rendered to an inmate while in custody have been brought against jailers. The number of such lawsuits is increasing. A recent publication of the American Medical Association has established guidelines and standards for health care in jails. 5 One method of augmenting these guidelines is to improve the skills of jailers in recognizing and managing medical emergencies and common medical problems. J a i l e r s should be t a u g h t such basic information as signs and symptoms of appendicitis and myocardial infarction, the common sense management of seizures and gastroenteritis, and the r e c o g n i t i o n of h e p a t i t i s a n d t u b e r c u l o s i s . A t a minimum, jailers should be proficient in adult cardiopulmonary resuscitation (CPR). 5 Most of the medical information t h a t a j a i l e r should know is closely related to the field of emergency medicine. The logical provider and director of such a course of instruction for jailers is the department of emergency medicine that is already providing s o m e w h a t s i m i l a r t r a i n i n g for e m e r g e n c y medical technicians and paramedics. The Division of Emergency Medicine at the University of Kentucky in Lexington, Kentucky has developed a 30-hour course to teach jailers the basics in management of common medical emergencies and recognition of depression and psychiatric emergencies. In addition, attention is given to techniques for the prevention of communicable diseases. The course is divided into nine self-contained modules (Table). Each module consists of a 20-minute video tape prepared by a physician followed by 20 to 30 minutes of classroom instruction conducted by a professional educator associated with the Kentucky Department of Correction (Bureau of Training). Each student is given a comprehensive syllabus for future reference. The module on cardiopulmonary resuscitation is given by American H e a r t Association instructors and fulfills the requirements for a "Heartsaver" course. This section includes adult CPR and the abdominal thrust maneuver but not infant resuscitation. The course was first given in April 1978 at Eastern Kentucky University, a central site for the training of jailers in the Commonwealth of Kentucky. Almost all Kentucky jailers will have participated in this course by December 1980.
Table COURSE MODULES FOR JAILER HEALTH CARE INSTRUCTION
I. Infectious Disorders A. Prevention and recognition of hepatitis. B. Screening for recognition and symptoms of tuberculosis. C. Recognition of syphilis and gonorrhea. Screening tests. I1. Diabetes Mellitus, Epilepsy and Burns A. The hyper- and hypoglycemic syndromes. Diabetic medications including insulin. Urine testing. B. Treatment of seizures (first aid measures). Facts (vs. myths) about epilepsy. C. Types of burns. D. When to refer a burn to a physician. III. Circulatory Disorders ', A. Recognition of myocardial infarction and angina. B. Cerebrovascular accidents. C. Risk factors including hypertension. IV. Diarrhea, Vomiting, Appendicitis A. Recognition and first aid treatment of common disorders of GI tract. B. Signs and symptoms of appendicitis. VI. Screening Examination, Management of Medications A. Fundamentals of the intake examination. B. When to refer a patient to a physician. C. A rational plan for medication control and inventory in the small jail and large jail. D. How to give medications (including insulin). VII. Medical Records System A. Implementation of the Commonwealth of Kentucky Department of Human Resources Medical Records System. VIII, Psychiatric Problems A. Drug overdose. B. Drug withdrawal a. alcohol b, barbiturates c, tranquilizers C. Anxiety neurosis D. Suicidal risk E. Treatment of suicide attempts F. A plan for psychiatric referrals
DISCUSSION The developers of this course and the Kentucky D e p a r t m e n t of Corrections hoped to develop j a i l e r s who would function as knowledgeable laymen r a t h e r than as health paraprofessionals. With this in mind, instruction in such things as blood pressure determination, examination of throats or venipunctures was deliberately avoided. The jailer places himself and his institution at an additional legal risk once he begins to perform any medical fdnctions. In the litigious atmosphere of jails, questions of malpractice or misjudgment may be considerable. T h e j a i l e r could not be expected to learn enough medical information to adequately assess a large variety of medical conditions. Jailers who have completed this course in Kentucky do not view themselves as health care providers but 64/378
IX. Respiratory Disorders A. Emphysema and chronic obstructive lung disease. B. Risk factors. C. When to refer the dyspneic patient. D. Bronchitis and pneumonia. E. The obstructed airway. F. Demonstration and discussion of abdominal thrust maneuver.
JACEP
8:9 (September) 1979
primarily as policemen or custodians who have been enlightened in some aspects of medicine. The process of accrediting h e a l t h care s t a n d a r d s in jails h a s a l r e a d y begun. I m p r o v e m e n t in h e a l t h standards m a y soon become m a n d a t o r y because of recent court r u l i n g s a n d because of the growing public awareness of the health care problems in jails. Eradication of the medical deficiencies in j a i l s m u s t begin with the j a i l e r s and their education is a vital part of this process. We anticipate t h a t t r a i n i n g programs for jailers will soon be started in other states. The A m e r i c a n Medical Association has a c o m m i t m e n t to the t r a i n i n g of jailers and has collaborated in the preparation of a program of i n s t r u c t i o n3 that is even more ambitious than the program conducted at the U n i v e r s i t y of Kentucky. E m e r g e n c y physicians should be aware of this new t r e n d in health care b e h i n d j a i l walls because
8:9 (September) 1979
they m a y be asked to participate in the t r a i n i n g of jailers w i t h i n the c o m m u n i t y i n the future.
REFERENCES 1. Sourcebook of Criminal Justice Statistics, 1976. US Dept Justice, Law Enforcement Assistance Administration, National Criminal Justice Information Statistic Services 523-48 Characteristic and Distribution. 2. Medical Care in US Jails, A 1972 Survey. Chicago, American Medical Association, 1972. 3. King L, Geis G: Tuberculosis transmission in a large urban jail. J A M A 237:791-792, 1977. 4. Isele WP: Constitutional Issues of the Prisoner's Right to Health Care. Chicago, American Medical Association, 1976, pp 1-24. 5. Standards for the accreditation of medical care and health services in jails. Chicago, American Medical Association, 2PA 1961: 78:00243:8/78, 1978.
JACEP
379/65
