Management in Custody

Staff should be reminded to wear gloves when coming into contact with detainees with infected skin sites exuding pus or serum and that any old dressings found in the cell should be disposed of into the yellow bag marked "clinical waste" in the medical room. Likewise, any bedding should be bagged and laundered or incinerated after use. The cell should be deemed out of use and professionally cleaned after the detainee has gone.

The health care professional managing the detainee should clean and dress open wounds as soon as possible to prevent the spread of infection. It may also be appropriate to start a course of antibiotics if there is abscess formation or signs of cellulites and/or the detainee is systemically unwell. However, infections can often be low grade because the skin, venous, and lymphatic systems have been damaged by repeated penetration of the skin. In these cases, signs include lymphedema, swollen lymph glands, and darkly pigmented skin over the area. Fever may or may not be present, but septicemia is uncommon unless the individual is immunocompromised (e.g., HIV positive). Co-Amoxiclav is the preferred treatment of choice because it covers the majority of staphylococci, streptococci, and anerobes (the dose depends on the degree of infection).

Necrotizing fasciitis and septic thrombophlebitis are rare but life-threatening complications of intravenous drug use. Any detainee suspected of either of these needs hospital treatment. Advice about harm reduction should also be given. This includes encouraging drug users to smoke rather than inject or at least to advise them to avoid injecting into muscle or skin. Although most IDUs are aware of the risk of sharing needles, they may not realize that sharing any drug paraphernalia could be hazardous. Advice should be given to use the minimum amount of citric acid to dissolve the heroin because the acid can damage the tissue under the skin, allowing bacteria to flourish. Drugs should be injected at different sites using fresh works for each injection. This is particularly important when "speedballing" because crack cocaine creates an anerobic environment. Medical help should be requested if any injection site become painful and swollen or shows signs of pus collecting under the skin. Because intravenous drug users are at increased risk of acquiring HBV and HAV, they should be informed that vaccination against both diseases is advisable.

Another serious but relatively rare problem is the risk from broken needles in veins. Embolization can take anywhere from hours to days or even longer if it is not removed. Complications may include endocarditis, pericarditis, or pulmonary abscesses (54,55). IDUs should be advised to seek medical help as soon as possible, and should such a case present in custody, then send the detainee straight to the hospital.

6.10. Management of Human and Dog Bites

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