Posts Tagged ‘back problems’

One of the most dangerous jobs in America

Wednesday, February 11th, 2015

NPR featured the first in a series of reports on one of the most dangerous jobs in America, one that they say has more debilitating back injuries than the construction industry or law enforcement. In Hospitals Fail To Protect Nursing Staff From Becoming Patients, Daniel Zwerdling investigates the high rate of back injuries that plague the nursing profession, largely the result of poor patient lifting practices, which are greatly exacerbated by the obesity epidemic.

The impact of obesity cannot be overstated – nurses are required to lift or support morbidly obese patients as many as 15 to 20 times a day. NPR puts this in context, citing NIOSH manager James Collins: “… before studying back injuries among nursing employees, he focused on auto factory workers. His subjects were “93 percent men, heavily tattooed, macho workforce, Harley-Davidson rider type guys,” he says. “And they were prohibited from lifting over 35 pounds through the course of their work.”

Yet nursing employees in a typical hospital lift far heavier patients a dozen or more times every day. Tom Lynch discusses safe lifting limits in a prior post:

“… according to NIOSH the most a nurse or aide in the 90th percentile of strength should lift at any one time is 46 pounds. But a typical 8-hour workday in this field involves lifting about 1.8 tons. Twelve percent of registered nurses who quit the field report that they do so because of back pain due to patient handling.”

A Case in Point

Zwerdling talks to a number of nurses who discuss their injuries and how they happened. He focuses on the experiences of nurses at Kaiser Permanante in Walnut Creek, which he notes is no worse and perhaps better than many healthcare facilities. Although the hospital had dedicated lifting equipment and teams, there were not enough machines and not enough teams to staff them when needed. When patients need help, the need is often urgent and immediate.

Nurses who worked at Kaiser Permanante asked for a state investigation into lifting practices shortly after California’s 2012 Hospital Patient and Health Care Worker Injury Protection Act went into effect. In January 2014, a state Administrative Law Judge issued an order that declared that Kaiser had failed to have “specific procedures in place to ensure that sufficient staff was available to perform patient handling tasks safely.”

While this report is one that frames the issue in terms of nursing injuries, it’s also a safety issue for patients.

The American Nurses Association tracks legislation related to safe patient handling and mobility (SPHM). They note that:

“…eleven states have enacted “safe patient handling” laws or promulgated rules / regulations: California, Illinois, Maryland, Minnesota, Missouri, New Jersey, New York, Ohio, Rhode Island, Texas, and Washington, with a resolution from Hawaii.

Of those, ten states require a comprehensive program in health care facilities (California, Illinois, Maryland, Minnesota, Missouri, New Jersey, New York, Rhode Island, Texas and Washington), in which there is established policy, guidelines for securing appropriate equipment and training, collection of data, and evaluation.”

Exacerbating Factors

In our prior post cited above, Tom talks about some additional factors contributing to the problem – the aging work force and nursing shortages.

“The average age of a registered nurse is now nearly 47. For Home Health Aides (HHA), it’s 46; for Certified Nursing Assistants (CNA), 39. Wages for the aides and assistants average between $11 and $12. Forty percent have been on food stamps and many get their own healthcare through Medicaid. (See: HHS Direct Care Workforce) The BLS (Bureau of Labor Statistics) estimates that the demand for HHAs between 2010 and 2020 will grow by 69%; CNAs, 40%. Collectively, we are confronted with a critical shortage of healthcare talent. According to the U.S. Department of Health & Human Services, “Direct care work is difficult, the wages are low and fringe benefits are often limited.”

It’s the same with registered nurses where, oftentimes, the shortage is self-inflicted. A study of 21 hospitals in the Twin Cities found that when registered nursing positions were decreased by 9%, work-related illnesses and injuries among nurses increased by 65% (Trinkoff, et al., 2005).”

Related Resources:

Prior Workers Comp Insider posts highlight other dangers involved in nursing:

Annals of Compensability: Oh, My Aching Pedicure

Monday, June 25th, 2012

Kelly Taylor worked as an accountant for Community Health Partners (CHP) in Montana. On her way out for lunch in May 2009, she slipped on the stairs and landed on her tailbone. Her primary caregiver, Rebecca Hintze, worked for the same employer and provided medical advice soon after the injury. The claim was accepted by the Montana State Fund. Taylor suffered from pain off and on over the following months, using up her sick leave in a random succession of 1-3 day episodes. She did not seek comp indemnity for these incidents as she mistakenly thought comp required 4 consecutive lost days.
Over a year later, in September of 2010, Taylor was sitting on a couch at home. She put her foot on her coffee table and bent over to paint her toenails. When she finished, she tried to stand up, but immediately had difficulty, experiencing extreme pain in her back and down the front of her leg. In the following weeks, she experienced this sharp pain two more times, once after stubbing her toe on a rug at CHP and again when she was scooping out cat litter. (For all the severity of the injury, this case is sublimely prosaic in terms of risk.)
Because of the long gap between indemnity payments, and because an IME found that the herniated disc following the pedicure was a new injury and not a recurrence of the old one, the claim was denied. Taylor appealed, and the case came before the estimable Judge John Jeremiah Shea, whom we have encountered a couple of times in the past: in the notorious “pot smoking with bears” incident, and in another complicated claim involving a non-compensable back injury.
Dispensing Dispassionate Justice
Judge Shea appears to be a relentless seeker of fact and a dispassionate purveyor of justice. While he praises both the IME doctor (for reasonably concluding that the pedicure incident involved a new injury) and the claims adjuster (for reasonably denying benefits), he over-ruled the denial and reinstated the benefits. He found continuity in the documented self-treatment and in the somewhat informal, ongoing treatment provided by Rebecca Hintze. While the IME doctor had stronger credentials and a longer track record, Hintze had “substantially more opportunities to observe and talk with Taylor about her injury in both formal appointments and in informal workplace conversations.”
He concluded that the pedicure injury was an aggravation of the back injury suffered over a year prior. At the same time, he denied an award for attorney’s fees to Taylor, as he found that in denying the claim, the adjuster had acted reasonably.
All of which might appear to be much ado about not much, but in the intricate and ever-evolving world of comp, this case embodies a core value of the system: the relentless effort to determine whether any given injury occurred “in the course and scope of employment.” Judge Shea, connecting the dots as methodically as a detective, concludes that the pedicure injury was an extension of the original fall. While the ruling itself can be questioned, Judge Shea’s method and discipline are beyond reproach .

Annals of Compensability: A Pre-Existing Condition

Tuesday, August 30th, 2011

We first encountered Montana workers comp judge James Jeremiah Shea last year, when he ruled that Brock Hopkins, a pot-smoking handyman, was eligible for workers comp after being mauled by a bear at Great Bear Adventures. In his ruling, Judge Shea managed to invoke the movie, Harold and Kumar Go to White Castle, to wit:

“It is not as if this attack occurred when Hopkins inexplicably wandered into the grizzly pen while searching for the nearest White Castle. Hopkins was attacked while performing a job Kilpatrick had paid him to do – feeding grizzly bears.”

In a more recent case, Judge Shea was confronted with the claim of Bruce Martin, a carpenter seeking treatment for what he insisted was a work-related back problem. While there is no reason to believe that Martin was partaking of Brock Hopkins’s favorite recreational drug, he did manage to present a narrative that consistently conflicted with the perceptions of virtually everyone else involved: his employer, Jesse Chase, co-worker Barry Hollander, and claims adjuster Michele Fairclough.
Martin claimed he injured his back while stripping the plastic protective barrier off of metal siding – a relatively light-duty task. But in walking off the job that morning, he stated to his boss that his sciatica was acting up and that it was not work related. Only after going to an Urgent Care clinic did he claim that the injury happened at work. Why? We can assume that he wanted his employer to pick up the tab through workers comp.
My Aching Back
Martin’s history of back problems began in the early 1990s, following a motor vehicle accident. He treated sporadically with Dr. Aumann, a chiropractor. Dr. Aumann, sympathetic to his long-term patient, thought that “on a more- probable-than-not” basis that Martin’s injury was the result of the work accident he described. Unfortunately for Martin, no one else bought his story, even as the story itself changed over time.
Judge Shea wrote:

Dr. Aumann identified objective medical findings to support Martin’s claim of lumbar spine problems. However, Martin has not established that this injury occurred because of a specific event on a single day or during a single shift. I did not find Martin’s testimony credible. Neither Hollander, who was working alongside Martin, nor Martin’s employer Chase could corroborate Martin’s account of injuring his back on June 29, 2010…

It is not altogether impossible to feel a little sympathy for Martin: he has a real back problem. He is experiencing legitimate pain. He has difficulty performing physical work and is not trained to do anything else. He desperately needs income. Martin is like a lot of other American workers in these troubled times, living day-to-day on the edge of disaster. While we can understand why he would try to stretch the facts to fit the workers comp mold, we acknowledge that he was wrong to do it. As Judge Shea concluded, Martin was not injured as the result of an industrial accident. Given that definitive ruling, Martin, bad back and all, is simply on his own.

Annals of Medicine: Refuse to Fuse?

Monday, February 21st, 2011

Dr. Trang Nguyen has some serious doubts about the effectiveness of spinal fusions, especially in workers comp. In his study of 1,450 cases of chronic lower back pain in the Ohio comp system, Dr. Nguyen focused on an outcome near and dear to the hearts of all comp practitioners: the number of injured workers returning to the workplace after surgery. The results of his compelling (if less than purely scientific) study, published in Spine Magazine, are cause for alarm.
Dr. Nugyen looked at cases involving chronic back pain that were at least two years old, divided equally among workers who had spinal fusions and those who did not. Among those with fusions, only 25% returned to work, compared to 66% among those who received conservative (non-invasive) treatment such as physical therapy.
That is a huge differential. In addition, 27% of the fused workers had to undergo a second surgery, and as any claims adjuster can tell you, doubling up on spinal surgery places workers on a downward slope toward failed back syndrome: permanent total disability. Among the fused workers, 11% were permanently disabled, compared to only 2% among those who avoided surgery. Finally, most of the workers who underwent fusions were still on strong opiates two years after the treatment. In other words, they still suffered from the pain that led them to treatment in the first place.
While this is not a definitive study, the findings surely offer a cautionary tale not only for workers who suffer from back pain, but for their families and employers as well. It is no great mystery why fusions have become the treatment of preference for so many medical specialists. One doctor used the analogy of giving out hammers: people with hammers – surgeons who can do fusions – look for nails (people who might need the treatment).
Something for the Pain
We are an impatient culture. When in pain, we want immediate relief. Given time, appropriate medications and the skilled hands of physical therapists and chiropractors, the pain usually goes away, or at least reaches more tolerable levels. To be sure, there are severe injuries when fusion is the necessary option; however, pain alone is not an indicator of such severity. The problem with fusion is that it creates rigidity in a part of the body that is designed for flexibility. A rigid spine is an open invitation to lifelong pain and despair.
From the comp perspective, we should remain aggressively sceptical of most proposed spinal fusions. Claims adjusters should routinely require a disciplined utilization review, an objective second opinion and an independent medical exam. Place a strong burden of proof on any doctor proposing fusion for an injured worker. Fusion should be the treatment of last resort.
These are not merely delaying tactics. Rather, they are essential strategies for buying precious time, time for the natural healing process to take place and time to avoid what often becomes a path to oblivion. If, as this study shows, the odds for return to work are more than double for workers receiving conservative treatment, then it is in everyone’s best interest to avoid fusion surgery. Refuse to Fuse. That’s a motto worth posting over the desk of every comp adjuster in America.

Disabled Carpenter Climbs a Mountain

Monday, November 9th, 2009

Christopher Robin Briejer used to be a carpenter. He suffered a back injury in 2000 and was disabled from work. Except that he apparently kept on working. In 2003 he hurt his back again while working without comp coverage. He claimed the new injury was a recurrence of the 2000 incident. The claim was re-opened and he began collecting benefits. Between January 2004 and April 2008, Briejer received 121 state checks totaling $258,995 for time-loss compensation, $75,295 in medical services and $31,651 in vocational retraining – for a total of nearly $366,000.
The state of Washington recently indicted Breijer for comp fraud, alleging that the 2003 injury was not a recurrence, but a new injury. Someone dropped a dime on him.
Breijer states: “I have a permanent back injury with permanent damage to my spine.”
For a man collecting disability payments, Breijer maintains a very active life style. He likes to “rock crawl” and last year he climbed Mount Ranier.
“It doesn’t take a back to climb a mountain, it takes legs,” he said. [Think about that for a moment.] “I’m an active injured person. Even though I’m injured, I take care of my body. My doctors are 100 percent in favor of me hiking.” Hmm. I wonder if his doctors are 100 percent in favor of him working…
A Famous Bear of LIttle Brain
Breijer appears to have been named after Christopher Robin, the boy who appears in the Winnie the Pooh books written by A.A. Milne. (I refer to the books, not to an abomination of the same name from the Disney folks.) It seems that Breijer took to heart one of the Pooh bear’s famous quotes: “A bear, however hard he tries, grows tubby without exercise.” No bear belly for Breijer!
I’m guessing that Breijer might resent being named after a character in a children’s book. Well, the original Christopher Robin resented it, too. Christopher Robin was based upon Milne’s own son, Christopher Robin Milne, who in later life became unhappy with the use of his name. “It seemed to me almost that my father had got where he was by climbing on my infant shoulders, that he had filched from me my good name and left me nothing but empty fame”. Children can be so harsh!
Well, as Pooh himself famously said: “People who don’t Think probably don’t have Brains; rather, they have grey fluff that’s blown into their heads by mistake.” And again: “If the person you are talking to doesn’t appear to be listening, be patient. It may simply be that he has a small piece of fluff in his ear.”
I wonder if the prodigiously active Christopher Robin Breijer might have just gotten a little confused, Pooh-bear style, between right and wrong, between being truly disabled and being able to work. Such confusion is rampant in these morally compromised times. It’s a bit like distinguishing one hand from another, which Pooh himself found to be quite difficult:

Pooh looked at his two paws. He knew that one of them was the right, and he knew that when you had decided which one of them was the right, then the other was the left, but he never could remember how to begin.

When it comes to confronting moral hazards, it’s really important to remember how to begin.

A new prescription for back pain

Wednesday, February 11th, 2004

I have long suspected that the way this country treats back pain for work-related injuries is not only ineffective, it’s actually destructive. I have seen countless back claims degenerate into permanent and total disability following surgery. We are now beginning to see data that bears this out. In an article with profound implications for employers, insurers and workers with lower back pain, New York Times (free registration required) reporter Gina Kolata demonstrates the futility and the ineffectiveness of our current approach to back pain. The data calls for a transformation of the treatment paradigm itself.
Here’s the way it works now: A worker suffers a lower back strain. He’s in a lot of pain. He goes for an MRI, which reveals a herniated disc. The insurer assumes that the herniation is work related, the condition is compensable and treatment begins. Perhaps surgery is performed. However, a number of studies have suggested that in 85% of the cases it is impossible to say why a person’s back hurts. Beyond that, many studies have found that abnormal disks are usually inherited, with no links to occupation, sports injuries, or weak muscles. So the use of the MRI to confirm compensability is indeed questionable.

Then there is the issue of treatment. Studies confirm that there is little evidence that aggressive treatment is in any way helpful to the patient. One doctor quoted in the article says, “Maybe you are better off not going to a doctor.” Under the current system, if the employee is lucky, neither the treatment nor the surgery will permanently disable him and, eventually, he will return to work. The irony is that in most cases, doing nothing at all would be equally or even more effective than treating the injury with conventional medicine!

So what is the new treatment paradigm? In the view of Dr. James N. Weinstein, a professor of orthopedics and editor in chief of Spine, we should teach people to live with pain, to put aside the fear that any motion will aggravate their injury. This is a concept that many Americans have trouble accepting. If we experience pain, we seek an immediate cure. For back injuries, this approach just doesn’t work. We have to learn that “hurt doesn’t mean harm.” There will be pain for a while. During the natural recovery process, treatment should focus on “functional restoration:” That means working on training, strength, flexibility and endurance. And let’s not forget to offer the needed counseling that addresses fears of reinjury, anxiety, and depression.

Which brings me back to the employer’s best tool for fostering an active (but not necessarily pain free) recovery: Modified duty. Once we recognize that the vast majority of back injuries resolve themselves in a few months, with little or no treatment required, the need for proactive employers to help injured employees through the process – and the pain – becomes paramount. By providing modified duty, we give injured employees a reason for getting up in the morning and a place to go. We give them meaningful tasks, which help take their minds off the pain. Above all, we help them maintain their identities as productive workers. This is by far the most effective and the least expensive approach to lower back injuries. As with so many other workers compensation issues, proactive management is the best solution.

Study shows active recovery fosters return to work

Thursday, January 29th, 2004

A recent study on lower back pain and return to work was conducted by a Dutch research team, and the findings were unsurprising to those of us who espouse the idea of an active rather than a passive recovery whenever possible. In the study, workers with nonspecific low back pain who engaged in a graded activity program returned to regular activities – including work – sooner than those who got “normal care.” On average, the active recovery path cut one month off a three-month recovery period, and follow-up studies showed no difference in the reinjury rate.

This study bolsters the case for employers to have a safe, progressive return to work program that eases injured workers back to their normal jobs. The study author comments:

“Athletes and other professionals are highly motivated, have high self-esteem, are not depressed, and have a strong motivation to keep doing what they always do,” he suggests. “Can we imbue the injured worker with some of the ideals and motivation of the injured athlete?” Based on the van Mechelen team’s study, the answer appears to be “yes.” Their program changes how disabled workers see — and cope with — their lower back pain.”

Dr. Jennifer Christian is an occupational physician who has worked in settings ranging from an insurer’s office to right on the shop floor. She often uses “the grocery store test” as a barometer of fitness for work. It goes something like this: If you worked in your family grocery store, would you be back at work, or would the injury or illness preclude that? Of course, it goes without saying that any worker’s return to work after an injury of illness must be planned carefully within physician restrictions.

The hidden key in both this study and the grocery store test may well center on that all-important word, motivation. If you are an employer, ask yourself this: would your employees be motivated to come back to your workplace?

By the way, if you ever have the chance to hear Dr. Christian speak at a national meeting or forum, do be sure to sign up…she is quite a forward thinker on workers compensation and disabilty issues.
And thanks to Judge Robert Vonada and his always excellent PAWC weblog for pointing us to this study.

New year’s news roundup from fellow ‘blogs

Sunday, January 4th, 2004

PA Judge Robert Vonada of PAWC points to an article in the New York Times about two different treatment options for back pain and the methods hardware manufacturers use to market their products to doctors and hospitals. Would you be surprised to learn that the more expensive treatment is prevalent, despite lack of evidence that it is more effective? We weren’t.

Confined Space has a scathing indictment of OSHA for its abandonment of a workplace TB standard and the public health ramifications that this might have in the era of SARS which requires similar precautions.

The Employers’ Lawyer informs us that the 2000 Census Data has recently been released, and also reports on an a court judgement involving a police officer who was discharged for no longer being able to fulfill his job requirements and the disability/ADA implications.

The HIPPA Blog has some advice for physicians on strategies for ensuring that medical privacy programs are in good working order.

A story posted on the Harvard Law School blog leads to an article on the University’s experience with building a community of 350+ webloggers among students and faculty.

Lifting guidelines and RTW

Monday, December 15th, 2003

The Ohio Bureau of Workers Comp and Ohio State University have teamed up on a research project that studies back injuries and reinjuries that can occur when people return to work. As an offshoot of the research, they developed an interactive lifting resource with guidelines intended to help employers and physicians in developing realistic transitional work programs. Considering that back injuries cause more time away from work than anything besides the common cold, it’s a resource worth checking out.