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By Expert ID: 19006, M.D.

There are two medical problems that often result in preventable disability or death during incarceration, especially in small, short-term lockups. The first is the inability to recognize and properly manage insulin dependent “brittle” diabetes mellitus. Violent behavior caused by poor blood sugar control sometimes leads to incarceration. This is then followed by inept management of the diabetes in the jail, leading to catastrophic medical consequences. Few jails know what constitutes a reasonable diabetic diet. Few are aware of the need to monitor blood sugar and mental status closely enough so they can be modified on a day to day basis, as needed. Most facilities seem to feel that if an inmate gets most of what they are prescribed most of the time, that is sufficient. Not so with brittle diabetics.

The second has to do with drug withdrawal without skilled medical supervision. Abrupt withdrawal from narcotic, anti-depressant or antipsychotic medication, whether prescribed or not, can lead to major physical and behavioral consequences. When dealing with an inmate with underlying cardiac, pulmonary or other major medical problems, it can be disastrous to just let them “dry out,” and then treat violent behavior with physical or pharmacologic restraint.

Most jails are staffed with Licensed Practical Nurses (LPNs), Licensed Vocational Nurses (LVNs) or Emergency Medical Technicians (EMTs). In the outside world, the scope of practice for LPNs and LVNs is limited to doing simple medical procedures (like taking vital signs) under the supervision of more qualified nursing or medical staff. There is nothing in their training that enables them to assess or diagnose inmate needs.

EMTs have a similarly limited scope of practice and requirement for supervision when working in an institutional environment. There is nothing in national guidelines or any state law that authorizes them to do any work in a jail they would not be permitted to do in a hospital or clinic. Yet, with rare exception, they operate as independent and medically unsupervised practitioners in jails, serving as the eyes and ears of the jail physician. That physician frequently orders medication on the basis of impressions and observations of unqualified on-site staff.

If that LPN, LVN, or EMT believes the inmate to be faking, or to be unworthy of medical attention, that inmate (at least in some jails) is cut off from any access to medical care, without recourse or appeal. In these not-uncommon cases, the complaints, physical signs and symptoms are not recorded in the medical record. As attorney or expert witness, one is then left with a seemingly unexpected adverse outcome and must depose family, other correctional staff and other inmates to determine what really happened.

Attorneys, whether for the plaintiff or defense, are urged to be sensitive to these issues. Attorneys are urged to play a lead role in reducing the risk of other inmates experiencing a similar fate. If left to their own devices, many facilities will either do nothing or implement the smallest of cosmetic paperwork changes, then proceed as if nothing happened.

Preventing recurrence of such disasters is most often accomplished with enhanced training and supervision of the on-site staff by more highly skilled nurses, as well as active involvement of a medical director with responsibility to oversee the totality of health-related services in the jail. Sometimes a few well-placed lawsuits can convince a sheriff that it would be cheaper and more politically expedient to upgrade the medical services than it would be to go to court or pay multiple out-of-court settlements.

By Expert ID: 19006, M.D.