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Injury and Trauma

Will the NFL Brain Injury Lawsuits Change the Game?

With the Super Bowl a receding memory, we are reminded about the physical nature of football in this Business Week article.

Many players and their families believe that football has been a source of permanent brain damage resulting from multiple head injuries in the course of play for some. A former Princeton quarterback in the 50s, Gene Locks, and a group of allied plaintiffs’ lawyers are taking up the cause and the league is on the defensive.

While Locks and other lawyers say they have no interest in putting the NFL out of business, they will represent more than 4,000 former players and their wives who accuse the $9.5 billion-a-year business of covering up life-altering brain injuries.

A protracted battle could provide the plaintiffs’ lawyers with an opportunity to reveal sordid details about a period during which they allege the NFL intentionally obfuscated evidence of the long-term brain damage suffered by its willing gladiators.

If this is true, and if the ugly particulars are played out in depositions, internal documents, and court testimony, such a legacy could alienate fans already uneasy about the suicides of former players such as Dave Duerson, Andre Waters, and Junior Seau, all of whom suffered from neurodegenerative brain disease linked to concussions.  Read More…

The outcome is far from decided and will be determined in part by public opinion, the courts, and hopefully additional meaningful scientific studies.

The Rising Need and Cost of Dialysis

The Seattle Times article, “The Dialysis Dilemma: Urgent Need vs. Overtaxed System,” gives an excellent historical account of the development, impact, and moral hazards involved in treatment of kidney failure.

In the early 1960s, dialysis became a long-term treatment option for select few. At $20,000 per patient, the three machines could treat nine patients. But money wasn’t the only issue.

Because of the limited number of machines available, a committee dubbed “The God Committee” or “The Life or Death Committee” was formed to decide who would be treated.

The committee members — a surgeon, a pastor, a lawyer, a banker, a state government official, a labor leader and a “housewife,” plus two physician advisers — were white. All but one were male.

Most patients they picked were well-off, white and male. Patients had to be able to pay for the treatment — $30,000 for three years, about $229,000 in today’s dollars. The committee also considered net worth, number of dependents, education and ‘future potential.’

Patients less than 25 or older than 45 generally weren’t eligible, nor were those with other illnesses.

Though our nation has seen significant progress in treating end-stage kidney disease since the “The Life or Death Committee, ” roughly 600,000 U.S. patients are affected by the disease and the costs are high.

In 2010, for each patient with end-stage renal disease on hemodialysis — the most common dialysis method — Medicare paid $87,561 on average, counting medications and other medical expenses. For those who dialyze at home, it was $66,751 per year, and for those who received a transplant, $32,914. Read more…

This once fatal disease has become survivable with dialysis and transplants. But the costs are high for society and the human lives involved very real.

Occupational Carpal Tunnel Syndrome & Potential Cost Savings

By Scott Smith, MD

carpal-tunnel1The cost of treating occupational carpal tunnel syndrome is three to five times greater than and the results considerably less successful than that of non-occupational carpal tunnel syndrome, though the pathology is the same in both.

The diminished success rate is a complex issue, not reviewed here.  However, the excessive costs can be reduced without affecting quality of care through a number of measures reviewed briefly below and confirmed by evidence-based medicine.

First, is reducing the number of claims accepted by more narrowly and accurately defining criteria for the allowance of carpal tunnel syndrome as an occupational disease.

The Washington Department of Labor & Industries Medical Examiner’s Handbook criteria are that it “must arise naturally and proximately out of employment” whereas the Washington Department of L&I Medical Guidelines for the Treatment of Carpal Tunnel Syndrome (2008) merely requires that the occupation “constributed to the development or worsening of the condition” – a much broader and vague definition in which almost any occupation could be interpreted contributory to carpal tunnel syndrome.

Better, in my estimation, would first, like Kansas, use the term “prevailing factor” rather than “contributory factor.”  Second, to use systematic literature reviews that list the occupations in which the risk of carpal tunnel syndrome is at least doubled compared with the general population.

Secondly, whereas the Washington State Medical Treatment Guidelines require electrodiagnostic studies when carpal tunnel release is being considered, they are in classical practice often not needed for diagnosis especially when the signs and symptoms are classic, in which case surgical results are still excellent.  Further, electrodiagnostic studies have only a limited role in predicting successful outcome of carpal tunnel release and hence do not fulfill this more important goal.

The American Academy of Orthopedic Surgeons’ (whose members do the majority of carpal tunnel releases) Clinical Practice Guidelines summary for carpal tunnel syndrome concurs with this conclusion, but add it in combination with history and physical examination, may be more predictive of successful results.  It is unclear, however, whether occupational carpal tunnel syndrome was included.

There are other reasons to decrease the use of electrodiagnostic studies.  For example, postoperative use to determine recurrence or degree of symptoms is not helpful because there is poor correlation with those symptoms and the severity or change in the electrodiagnostic studies.

Third, ergonomic evaluations and recommendations seem to be overused.  Ergonomic modifications of the workplace at least intuitively, given the association of carpal tunnel syndrome with various activities involving repetition, vibration, force, and awkward postures, should diminish the incidence of carpal tunnel syndrome in the workplace and reduce its symptoms. Hence, the Washington L & I Medical Treatment Guidelines recommend “ergonomic assessment of work site within two weeks of the first healthcare visit for people with carpal tunnel syndrome to assist with work modification.” Nonetheless in a series of 24 studies on the subject in the year 2000, none of them conclusively demonstrated that the interventions would result in the prevention of carpal tunnel syndrome or its amelioration in a working population.  They do not seem therefore to be a cost-effective intervention.

Lastly and for multiple reasons, return to work issues are always very important in a workman’s compensation setting and an important concept because in genera, return to work is actually in the best interest of the worker as well as the employer. 

Medical Disability Guidelines have recommended optimum return to work durations after carpal tunnel release that range from two to eight weeks depending on the work classification, whereas other “optimum recommendations” are from 0 to 4 weeks, demonstrating considerable variation.  Considering the relatively simple nature of carpal tunnel release, return to work for sedentary and light job classifications should actually be less than one week.  Longer periods would reflect worker desires and pain tolerance rather than any risk of harm.

In association with return to work are Functional Capacity Evaluations (FCEs), though less commonly done for carpal tunnel releases than other conditions, their purpose is to improve return to work by determining what limitations, if any, are required physically. In fact, for reasons beyond the scope of this brief review, that is unfortunately not the case and can even diminish the chances of return to work compared with giving no restrictions.

Summary: The above are methods that without altering quality of care, could potentially lead to significant cost savings in diagnosis and treatment of carpal tunnel syndrome in the occupational setting.  According to an August 2012 Washington Department of Labor and Industries news communication, L & I is currently contracting with an independent researcher to study occupational disease claims in Washington.  Hopefully some of the cost savings noted above would be considered.

 D. Scott Smith has been an Orthopedic Surgeon who has worked on MCN’s provider panel for 12 years and has spoken at CEU events sponsored by MCN. To learn more, please email MCNTalk@mcn.com.

Deadly Meningitis Outbreak: Were Spinal Injections Necessary?

The tragedy of  deaths caused by the contaminated steroid vials is especially sad when one considers that in many cases, spinal injections may offer no benefit.

The New York Times article, “How Back Pain Turned Deadly,” addresses the October meningitis outbreak and the 25 victims who are now suing the New England Compounding Center for injury, illness, and deaths  caused by the spinal injections.

“Studies are at best inconclusive about exactly which groups of back-pain patients are likely to benefit from steroid shots. Though some patients clearly get much-needed relief, health researchers are nearly unanimous that the treatment is vastly overused in the United States.

But Dr. Laxmaiah Manchikanti, head of the American Society of Interventional Pain Physicians, said the increasing number of spine injections was just part of ‘an exponential increase in all interventional techniques’ and is a good thing, reflecting a better understanding of chronic pain and patients’ demands for improved pain relief.”

The statement by Dr. Manchikanti would appear to contradict academic researchers and such statements are commonly made by advocates of a particular point of view, citing a ‘better understanding of chronic pain and patients’ demands for improved pain relief. This sort of uncritical thinking or statement can be made by any of the many proponents for increased use of narcotics such as Oxycontin, which we have covered in our blog.

“Though doctors are still arguing, most academic researchers say there is no evidence that steroid injections are useful in easing straightforward chronic low back pain. Professional guidelines say such shots should generally not be used for back pain that is less than four to six weeks old, which studies show almost always gets better with noninvasive treatments. Although many Medicare patients get spinal injections to treat a condition called spinal stenosis, a narrowing of spaces between bones of the spine, Dr. Friedly said, shots are not used for that condition in many European countries.” Read More…

If one wants to do good, one must first ensure that one is doing no harm. Steroid injections to the spine and narcotics for chronic pain would not appear in many cases to meet this standard.

How many of the deaths and the sick stood to gain from the treatments they received? How many facilities and practitioners, as well as the pharmacy did just fine until people started dying?

Washington Couple Charged with Stealing $223,000 in Workers’ Comp

After nearly two years of receiving workers’ compensation benefits, a Tacoma, WA couple has been charged with one felony count each for illegally collecting $223,758 in workers’ comp benefits.

From March 2009 through July 2011, Jamie Beroth, 63, collected $100, 664 on a shoulder injury she claimed happened on the job. Her husband,  Lawrence Beroth, 67, also received $123,094.02 in time-loss benefit payments from August 2009 to October 2011 for an industrial injury. Both claimed they could not work during this period.An investigation by the Washington State Department of Labor & Industries found that the couple had continued to work on their drywall company ever since the alleged work injuries occurred. The couple was arraigned in Peirce County Superior Court on November 15, 2012 and pled not guilty.

“We discovered that Mrs. Beroth continued to work at Beroth Drywall after her injury, actually preparing and submitting her husband’s injury paperwork to L&I…

We also took videos of Mr. Beroth working at his drywall business during the time he was receiving benefits and claiming he could not. The video shows him submitting bids, purchasing and hauling supplies, preparing for and working the jobs he received,” ” said Greg McPherson, an investigator in L&I’s Fraud Prevention and Compliance Program.

Not only could they be forced to pay restitution in full, but they are also  faced with a maximum penalty of 10 years in prison and a $20,000 fine each.

Workplace injuries are unfortunate events for those who suffer legitimate injury and we believe they deserve proper care and assistance as they recover. However, with every workers’ compensation claim, we believe the goal should be for an employee to receive the most effective treatment so they can return to work in due time.

Unfortunately, situations and people like this cast a pall on legitimate claims and claimants.

Read More…

9/11 Health Program Will Now Cover 58 Types of Cancer

First reponders searching for victims at Ground Zero after WTC collapse.
Photo by Frank Schwere

In memory of the September 11th terrorist attacks,  first responders, construction workers, volunteers and survivors who helped with rescue and recovery at Ground Zero have reason to be even more hopeful today. The World Trade Center Health Program recently added 58 new types of cancer as a service that would be provided under the James Zadroga 9/11 Health and Compensation Act of 2010.  The act was initially signed by President Obama  in 2010 to provide health coverage to those who lived, worked or attended school in the immediate area of the 9/11 attacks. The Act was named after New York City police detective James Zadroga, who died after working at the site.

The Federal government set aside $4.3 billion dollars for 9/11 victims who had been exposed to airborne toxins and acquired adverse conditions such as asthma, acid reflux disease, back pain and chronic sinus irritation, etc. Though cancer had not originally been drafted in the act, studies have shown that over the course of 11 years the link between the 9/11 toxic dust cloud and cancer may be more evident.

Analysis found that substances in the dust included cement, gypsum, asbestos, glass fibers, calcium carbonate, lead and other metal particles.  Lead and other heavy metals can be toxic to the brain, and gypsum, a component of drywall, can cause respiratory problems if it’s inhaled over a prolonged period of time.

In an interview with ABC World News, Dr. Philip Landrigan, dean of global health at the Mount Sinai School of Medicine in New York explained that those who were in the immediate area during the attacks could have been exposed to an abnormally large amount of these toxins.

“That means it’s extremely caustic and would be like inhaling powdered lye or Drano… Asbestos is a human carcinogen. It causes lung cancer, laryngeal cancers and malignant mesothelioma, and these typically develop anywhere from 10 to 30 years after exposure.”

While it has not yet been proven whether the 9/11 dust cloud was the cause of cancer, the lobbying efforts of construction workers, firefighters, police officers, and others who fell ill a decade after the terror attack  was enough to convince the government to add health coverage for cancer to the list. Read More…

Earphones As Damaging As Jet Engine Noise?

It seems like nearly everyone you encounter, from kids to seniors, is constantly interacting with their cell phone, computer, MP3 player, game console, e-book reader or tablet computer. And while it may be the social norm now, scientists and researchers are watchful to figure out whether our hypeconnectivity could have adverse effects on our health.

A recent study by scientists from the University of Leicester found that listening to high volume on your headphones can damage the coating of nerve cells in your ears, causing temporary deafness. While it depends on the type of headphones you use,  how loud and how often you use them, you could be subjecting your ears to noise levels similar to that of a jet engine.

The study showed that exposure to loud noises 110 decibels and higher can strip the cells of a coating within our ear called the myelin sheath, which helps the electrical signals travel along the cell. The excessive noise disrupts the electrical signals which means the nerves can’t efficiently transmit information from the ears to the brain. So if you’ve ever turned your iPod up near maximum volume for extended periods of time , you’ve likely been listening to your music at 110 decibels, the same noise level as a jet engine.

Sound is measured in decibels and it may surprise you how some of your daily activities may be noisier than you think. Here are some decibel levels of common sounds:

  • Firecracker: 150 dB
  • Ambulance siren or airplane taking off: 120 dB
  • Nightclub: 120 dB
  • Jet engine: 120+dB
  • Movie theatre: up to 117 dB
  • Rock concert: 110-125 dB
  • Listening to music with headphones: 105-120 dB if the volume is cranked up to the maximum setting (earbuds, which you insert directly into your ear, can add 6-9 dB to the volume)
  • Motorcycle: 95 dB
  • Noisy restaurant or heavy traffic in the city: 85 dB
  • Normal conversation: 60 dB
  • Fridge humming: 40 dB
  • Whispering: 30-15 dB

Believe it or not, being exposed to anything louder than 85 dB for extended period of time can cause permanent hearing loss and it’s often irreversible. Also, an occasional loud noise may cause you less loss then extended exposure of a much quieter sound. For example, 8 hours at 85 dB causes as much damage as 4 hours at 88 dB, 2 hours at 91 dB, or just 15 minutes at 100 dB.

However, the study also showed for the first time that the coating surrounding the nerve cells can reform, letting the cells function again as normal. This means hearing loss can be temporary, and full hearing can return, the researchers said. In an article by Science Daily, Dr Hamann explained:

“We now understand why hearing loss can be reversible in certain cases. We showed that the sheath around the auditory nerve is lost in about half of the cells we looked at, a bit like stripping the electrical cable linking an amplifier to the loudspeaker. The effect is reversible and after three months, hearing has recovered and so has the sheath around the auditory nerve…The work will help prevention as well as progression into finding appropriate cures for hearing loss.” Read More…

The new research could lead to the first drug treatments to prevent the development of tinnitus (ringing in the ears)and/or cures to hearing loss but it is still an ongoing project. Regardless, we should always protect our ears, limit our headphone use and keep the volume below sixty percent.

The 10 Essentials, Good Judgment and Preparation Will Save More Lives Than Any Technology

When folks in the Northwest learn about outdoor survival, they learn about the “10 essentials”. The list was developed by The Mountaineers as a guide for explorers if they ever need to face these two questions: First, can you respond positively to an accident or emergency? Second, can you safely spend a night—or more—out?

The reality is that today most who enter the wilderness bring along technology in the form of a mobile phone, or as the New York Times article, “When GPS Leads to S.O.S” describes, a P.L.B. or personal locator beacon. Such tools are wise, but they are certainly problematic if their possession leads to imprudent decisions to enter the wilderness unprepared for events that are otherwise predictable to experienced outdoor explorers.

These unnecessary and  inappropriate requests for help, or acts of plain rudeness and stupidity towards the wilderness rescue system are wasteful and costly, but also pose a bigger problem. The article states, “While in some countries like Europe,  inexpensive rescue insurance covers the costs of all rescues, while in others, those rescued must pay for the help, especially when “victims” are thought to have been negligent or to have cried wolf. But in the United States, charging hikers or boaters for unnecessary rescues is an option seldom pursued. “We don’t want people not to call for a rescue because they think they can’t afford it. Then they’re likely to get into deeper trouble and trigger a more dangerous rescue,” says Jeff Sparhawk, public information officer for the Rocky Mountain Rescue Group, a search-and-rescue team based in Boulder, Colo.” Read More…

Professional and volunteer rescuers believe in their missions and want to help, but they put their own lives at risk in the process. The 10 essentials, good judgment and prudence, including the willingness to turn back, well short of the summit or goal will save more lives than any technology. Failure is one of the allures of the outdoors. There is always another weekend or another season to try again, and the journey, not the destination ought to be enough.

 

 

Painkillers May Delay a Return to Work

At MCN talk we frequently blog about the opioid problem nationwide. Here’s a good reason why we do so: as per this article in The New York Times, the way that certain types of pain killers such as Oxycontin are prescribed for specific injury types may actually delay a return to work.

It’s important to establish that there is little question that strong pain medications can help some patients return to work and remain productive.  The ability to return to work is a major event in a person’s life—this is not about a perception of “slacking off” (i.e. the injured party is just malingering and really ought not to be a drain on someone else’s dime) but rather it’s a sign of improved health and functionality. Returning to work is an important step for a person in returning to their pre-injury life. Pain medication is meant to aid in reaching that step in the recovery process, not hinder it. So what’s going on?

Workplace insurers spend an estimated $1.4 billion annually on narcotic painkillers, or opioids. But they are also finding that the medications, if used too early in treatment, too frequently or for too long, can drive up associated disability payouts and medical expenses by delaying an employee’s return to work.

Workers who received high doses of opioid painkillers to treat injuries like back strain stayed out of work three times longer than those with similar injuries who took lower doses, a 2008 study of claims by the California Workers Compensation Institute found. When medical care and disability payments are combined, the cost of a workplace injury is nine times higher when a strong narcotic like OxyContin is used than when a narcotic is not used, according to a 2010 analysis by Accident Fund Holdings, an insurer that operates in 18 states. Read more…

Doctor Revolt Shakes Disability Program

An interesting article in The Wall Street Journal, for those of us in the disability assessment world. Briefly, earlier this year, senior managers at the Social Security Administration in Baltimore, frustrated by a growing backlog of applications for federal disability benefits, called meetings with 140 of the agency’s doctors. The message was blunt: The number of people seeking benefits had soared. Doctors had to work faster to move cases. Instead of earning $90 an hour, as they had previously, they would receive about $80 per case—a pay cut for many cases which can take 60 to 90 minutes to review—unless the doctors worked faster. Most notably, it no longer mattered if doctors strayed far from their areas of expertise when taking a case.

So  what happened? Some doctors quit following the changes. Others were fired. In all, 45 of the 140 left within months, the agency said. The upheaval, described by current and former doctors and agency officials, is the latest strain on a cash-strapped program struggling to deal with a giant influx of applications. Read more…