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The relationship between physician and patient is one of the oldest and most protected bonds. However, in the often complicated situation of treating an occupational illness or injury, the private relationship becomes more public with the additional agendas of an employer and an administrator. Keeping the ultimate goal of improving patients’ conditions in mind can carry physicians through the ethical considerations.

When presented with a workers’ compensation case, every physician should familiarize him or herself with the forms and regulations for treatment of occupational illnesses and injuries in the state in which the condition developed, as well as the state in which treatment will occur, should the two be different. Clear communication with all parties involved in the cases, an evidence-based treatment plan and a realistic prognosis will ensure the best outcome for the patient, regarding employment and health.

The Guidelines

As re-establishing a functional ability is the primary goal for workers’ compensation cases, using a series of objective measures to track progress removes the chance for personal bias. Physicians should watch for decline or improvement in ability to perform daily living activities, cognitive and psychological behavior, range of motion, stamina and strength through a follow-up visit every two to three weeks.

While the patient’s experience of pain should be documented, it should not singularly determine the length of his or her leave or type of treatment. In setting a patient’s return-to-work date, physicians should utilize resources such as the Medical Disability Advisor and the Official Disability Guidelines. Adhering strictly to personal opinion or patient requests can jeopardize a patient’s employment status and put the employer in the dark regarding its employee’s condition. Also, the American Medical Association’s book The Physician’s Guide to Return to Work offers body system-specific treatment plans and case-by-case examples for effective negotiations.

Paperwork 101

States require different forms to communicate among the three to four parties involved and document the varying stages of treatment. The standard paperwork typically includes a first report detailing the physician’s initial examination and course of action, progress reports that record any major change in condition or treatment proposal and a final report that makes a definitive determination about the nature of the illness or injury.

Most documents are extremely time sensitive and have implications for a physician’s reimbursement, as well as an employer’s planning and a patient’s future employment.

Upping Fees to Cut Costs

A persistent stumbling block for the proliferation of quality physician care and occupational health programs is the low fee schedules associated with physician reimbursement. However, the American College of Occupational and Environmental Medicine (ACOEM) is supporting a movement to realign the schedule with a “pay for performance” philosophy. The organization argues that offering higher reimbursement levels, in addition to requiring the adoption of its Occupational Medicine Practice Guidelines, will grow the number of physicians providing care for workers’ compensation cases and enhance the patient outcomes as physicians will be following guidelines for treatment drafted on the latest scientific studies. ACOEM guidelines have already provided the standards for California and New York state policies and include measures for preventive medicine to head off complications resulting from an occupational illness or injury.

MD News April 2011

Buffalo, NY (WBEN) — Anthony Thompson, the man accused of causing a car crash that seriously injured an off-duty Buffalo Police officer, has pleaded not guilty to all of the charges lodged against him.

Thompson was arraigned Wednesday in State Supreme Court. Judge Penny Wolfgang set Thompson’s bail at $500,000.

Thompson, 22, was allegedly driving drunk when he ran a red light at Main and Ferry Streets in Buffalo on February 25. His car violently struck the vehicle of Officer Gary Sengbusch, who was off-duty and driving home from his second job at the time.

Sengbusch was hospitalized at Erie County Medical Center for over a month after the crash. He suffered numerous a broken pelvis, had to have his spleen removed, and for weeks had no feeling in his left side. He’s now in rehab and continues to recover.

A passenger in Thompson’s vehicle, 20-year-old Honey Ransom of Buffalo, died of injuries she sustained in the accident.

Thompson’s next court appearance is May 10.

Read more: http://www.digitaljournal.com/pr/279192#ixzz1JbjMzQsh

What is a Wrist Strain?

Wrist injuries are a more common problem among athletes. They are common because people have a natural instinct to put their hands out for support when they are falling to catch themselves. In doing this the wrist can be twisted, often with sudden force, and an injury, such as a wrist strain, can occur.

A wrist strain occurs when the muscles or tendons of the wrist, which are attached to bones that allow motion, are injured. Other parts of the body involved in a wrist strain include the soft tissues that surround the strain, including ligaments, nerves, blood vessels, lymph vessels, and the layers of tissue that cover the bones of the forearm.

Wrist strains can be aggravating not only because they are painful, but also because we are so dependent on the use of our hands that a wrist injury may hinder us from participating in sports we enjoy for some time as the healing process takes place. There are three types of wrist strains and they are graded according to the severity of the injury. The three types are as follows:

Mild (Grade I): This is a mild injury in which the ligaments have been stretched beyond their normal limits. The muscles may be slightly pulled but there is no tearing of the tendons or the muscles. There is no loss of strength with this grade of a wrist strain.

Moderate (Grade II): This is a moderate injury in which there is some partial tearing of the ligaments, muscles or tendons. Strength is not completely lost but is significant.

Severe (Grade III): This is a severe strain in which the ligaments are torn completely. The attachment of the muscle, bone, and tendon is ruptured and there is a separation of the fibers of the muscle. Strength is greatly diminished and the joint may become unstable. Severe wrist strains generally require surgery to be repaired.

What Causes Wrist Strains?

The majority of wrist strains occur after a fall, such as slipping on ice in cold weather or when participating in certain a sport. The second most common cause of a wrist strain is prolonged overuse of the muscles and tendons in the forearm. Wrist strains are seen in sporting activities including, but not limited to, football, basketball, skating, rollerblading, street hockey, skiing, and snowboarding.

Taking certain measures when participating in specific sports can prevent wrist strains. For example, it is better to use poles that have a low-profile grip and not to secure the wrists to tightly in straps. When playing sports such as street hockey and football, or during rollerblading, skiing, and snowboarding, it is helpful to wear splints that will protect the forearms and the wrists.

What are the Symptoms of a Wrist Strain?

The most common symptom of a wrist strain is pain with movement or stretching. There may also be swelling around the joints and bruising, redness, or discoloration of the skin around the area of injury. Some patients have also complained of a burning or tingling sensation around the wrist.

Other symptoms include spasms of the muscles in the forearms, a loss of strength to varying degrees depending on the severity of the strain, an inflammation of the exterior covering of the tendon, calcification of the muscles or tendons, and a syndrome known as crepitation. Crepitation is when there is a feeling and/or sound of “crackling” when the injured area is palpated pr pushed on.

How is a Wrist Strain Treated?

Wrist strains are considered acute injuries. Most acute injuries, depending on their severity, are treated with the “RICE” method. “RICE” stands for Rest, Ice, Compress, and Elevate. A basic description of each is as follows:

-Rest for the first 24-48 hours after an injury is very important. Continuing to use the injured area can potentially make the injury worse and can even cause permanent damage. Use of the injured area should be increased gradually and only as tolerated.

-Ice used for the first 24-48 hours after an injury, ice is also important as it will help to reduce swelling of the joints and decrease pain. Ice packs are applied every three to four hours for approximately 20 minutes at a time. A wrist strain should NOT be iced for more than 20 minutes at a time.

-Compression is physically applying pressure to the area of an injury. The most common way compression is applied is to use an Ace bandage. The wrist should be wrapped from the base of the fingers to the top part of the forearm. Compression wraps should be snug enough to give support but not so tight as to cut of blood circulation. Compression is most useful in helping to reduce swelling of the joints.

-Elevation also helps to reduce swelling and promotes healthier circulation. The strained wrist should be held at a level above that of the heart.

While using the RICE method if there is still minor discomfort, over-the-counter medications such as aspirin, ibuprofen, or acetaminophen may be used to relieve pain. Topical ointments and creams, such as “Icy Hot” are also available to help reduce pain.

As a nationally certified Medical Assistant, I have had the opportunity to work in several different fields of medicine, including sports medicine. Wrist strains are very common injuries and can be treated at home if they are minor to moderate. A surgeon usually treats more severe injuries to repair damaged muscles, tendons, and ligaments.

Sources

Parker, James N. The Official Patient’s Sourcebook on Wrist Sprains and Strains. San Diego, CA: Icon Health Publications, 2002.

Walker, Brad. The Anatomy of Sports Injuries. Berkeley, CA: North Atlantic Books; 1st Edition, 2007.

Siegel, Irwin M. All about Joints: How to Prevent and Recover from Common Injuries. New York, NY: Demos Health; 1st Edition, 2002.

WASHINGTON — Army 1st Sgt. William “Mike” Leonard found himself mourning the left leg that he had agonized for months about keeping. It was in December, just weeks before he would have doctors cut it off.

“There were a couple of nights,” the company sergeant recalls, “where I sat in the shower and just kind of had some tears about losing it.”

• PHOTOS: Why this sergeant chose amputation

But the bomb blast in Afghanistan that had taken his right leg on March 22, 2010, had so damaged the left one that bones stubbornly resisted mending. Standing on the left limb was excruciating. Leonard could see other amputees at Walter Reed Army Medical Center up and running on new, high-tech prosthetics. “Why am I still in a wheelchair?” he asked himself during months of internal debate.

• PHOTOS: Why one sergeant chose amputation

Doctors amputated Leonard’s remaining leg on Jan. 10. Within weeks, he was standing on gleaming new artificial limbs, balancing on bright green Nike Air Max running shoes, and sweating over a hip exercise machine.

“It’s nice to get up and get going finally,” says Leonard, 40.

Wounded soldiers and Marines are making choices about arms and legs that predecessors from earlier wars never had: whether to trade poorly functioning flesh-and-blood for microprocessor-driven substitutes. Advanced prosthetics created to replace limbs lost in battle now are being sought by troops with legs or arms that survived combat, but are not functioning well or are still causing great pain after months or even years of physical therapy.

What doctors call delayed amputations — defined as when limbs are removed three months after an injury — now make up 15% of all combat-related amputations, according to research in Military Medicine published in December. That’s up from a 5% military rate cited in a 2008 analysis in the Journal of Orthopedic Trauma, and far higher than the civilian rate of 3.9%.

Since the wars in Iraq and Afghanistan began, 134 troops — 101 soldiers, 23 Marines, six airmen and four sailors — have chosen to have their limbs removed and replaced with prosthetics months or years after being hurt, according to the Army, Navy and Air Force. The longest period between an injury and an amputation was five years, Army doctors say.

The vast majority involve removing legs rather then arms, the doctors say. The largest number of these surgeries occur here at Walter Reed, with smaller numbers of delayed amputations performed at Brooke Army Medical Center in San Antonio, Naval Medical Center San Diego and Bethesda Naval Medical Center in Maryland.

To avoid giving up too soon on limbs that could be salvaged with time and effort, doctors here have developed an informal protocol for handling such cases, says Army Maj. Benjamin Kyle Potter, an orthopedic surgeon who performs most of these elective amputations.

They encourage patients contemplating amputation to have a lengthy period of reflection and consultation with doctors, physical therapists and other amputees, sometimes lasting weeks or months while they work to improve the damaged limb. Any possible candidate for amputation is required to meet with a mental health specialist. And patients are urged to seek second opinions.

“It’s something that we struggle with consciously and transparently in order to make sure that patients who are considering delayed amputation are doing so for the right reasons,” Potter says. “These kids are 20, 24 years old and you want to make sure that they’re not doing it for the quick fix. … An amputation is certainly something that is forever. And it’s something that we as a team and I as a surgeon consider very seriously.”

‘This can’t be happening’

Leonard doesn’t remember the blast.

He vaguely recalls a medic grabbing him by his body armor and urging him to lay down after Leonard apparently was trying to stand on a shattered right leg and damaged left one.

His wife, Cheryl Leonard, back home near Fort Lewis, Wash., recalls it like it was yesterday: the phone call with a curious preamble of questions — “When was the last time you heard from your husband? — before the news was delivered. She furiously scribbled every word into a notebook.

Her husband had survived combat tours to Baghdad and Ramadi in Iraq. Now a company sergeant, he was not supposed to be going out on routine patrols, Cheryl thought. “I’m thinking, ‘This can’t be happening,’ ” she recalls.

It was their third separation caused by war since the two had married in 2003 after — by military standards — a storybook romance.

In 2002, she had been dragged to a recruiting center by her son from a first marriage, who was toying with enlisting in the Navy. The Navy recruiter was out and soldiers in the Army recruiting office nearby, where Mike worked at the time, waved her and her son inside. Mike says he was smitten. The son never enlisted, but Mike and Cheryl began meeting over coffee.

A year later, Mike was so eager to marry her before going to Iraq that they exchanged vows in a phone call — he in Germany and she in an Oregon courthouse, with a judge on a speaker phone. “It was our fairy tale wedding,” Cheryl says.

Early last year before heading to Afghanistan, Mike suddenly raised the issue of what medical care should or should not be taken if he were severely wounded. The result was that he signed papers directing doctors not to resuscitate him if he were left on life support.

He was haunted by one possible outcome, Mike says: “I didn’t want to be a double amputee.”

Cheryl knew this too well when she caught up with her husband in the intensive care ward at Walter Reed after the blast.

She was told that Mike had nearly died. Doctors twice had revived him at an Army hospital in Germany during his transit from Afghanistan. His right leg below the knee was gone. He was unconscious. And doctors were urging her to let them remove Mike’s surviving, damaged lower left leg.

The blast had shattered or even obliterated bones in the left heel and foot. What was left would likely not mend and the pain would be intense if Mike eventually tried walking on it, doctors warned.

But aware of her husband’s worst fear of losing both legs, Cheryl declined. “I told them that he has a high tolerance for pain and I think he needs to be the one to decide,” she recalls.

In a heavily medicated state, Mike was dimly aware of his broken body, Cheryl recalls. At one point, tears streaming down his face, he asked her to have doctors remove his feeding tube and let him die. “Mike, you’re fine,” Cheryl recalls pleading with him. “You’ve taken care of me for many years and so it’s my turn now. So you just heal and get better so we can get back to our lives.”

He also had suffered a traumatic brain injury from the blast. But his head was clearing by late April and early May of last year. “I came out of the haze and fog and started really realizing what was going on,” he says. “I still had my left leg. But I couldn’t use it.”

Depression set in for a few weeks. Mike met with an Army psychologist. And there were infections and more operations on his left foot.

Amputation’s advantages

Soldiers in previous wars had the option of amputation for a damaged leg that was not getting any better. But they didn’t have the array of advanced artificial limbs available today: bionic feet fueled by lithium batteries, mechanical legs with microprocessors that anticipate movement and curved carbon-fiber prosthetics that allow high-performance running.

The choice of an artificial alternatives is better than ever.

Fueling the decisions to amputate are the living and rehabilitation environments at the military’s leading hospital. There, amputees work side by side in physical therapy with troops trying to salvage damaged arms or legs.

Every day in the halls of housing complexes or in the rehabilitation centers, service members who are working to save their limbs make comparisons with those who have lost legs and are more rapidly becoming mobile on prosthetics.

“Some, if not most, of our delayed amputations were influenced in their decisions by their frequent interaction with other amputees,” according to published research on the trend by Army doctors.

Doctors say that those patients trying to save their limbs grow frustrated with time.

“(Amputees) are up and walking — potentially running — faster, when a similar person undergoing limb salvage is … having additional surgeries with months of continued rehab and operations ahead of them,” Potter says.

“I think we’ll see late amputations continuing, the numbers will increase,” says Col. James Ficke, the orthopedic consultant to the Army Surgeon General, who has performed these operations at Brooke. “Because as the injuries occur, and you go through your life (with ongoing pain or lack of function) you’ll finally say, ‘I am tired of this. I want something different.’ ”

Doctors warn that artificial limbs are not free of problems. Research shows that even with advanced prosthetics, the human body will not function as it did before, Potter says. There can be long-term costs — lower back pain and arthritis — that get worse with age.

Even so, patients can be insistent on amputations. A few with elective amputations have manage to return to active duty, doctors say. Ficke says the decision to agree to an amputation can be “gut wrenching” for doctors.

“This is final,” Ficke says of the operation. “I never want a patient coming to me (in the future) and saying, ‘You took my leg off and that was a mistake,and I regret it.’ ”

What tormented Mike Leonard, besides his failure to regain mobility, was how the damage was confined primarily to his left heel and foot, where bones were gone or failing to knit together with time. When he was alone in the shower looking down at the limb, it nearly looked undamaged.

And if he chose amputation, Mike would not simply lose his left foot, doctors told him. To even the stress on his body, they would amputate at the same location where he lost his right leg — about five inches below the knee.

He struggled with a decision for nine months last year. Mike and Cheryl consulted with civilian doctors who were equally pessimistic about his left leg’s recovery.

At best, they told him, he would have a limp and never run again.

“Stairs would be difficult. Uneven terrain would be difficult,” Mike says. “I mean it was just one bad prognosis after another.”

And Cheryl was noticing how Mike enviously watched amputees at Walter Reed active on their prosthetics.

“He was in the wheelchair more often than not,” she recalls, “He said, ‘Honey, I’m a double-amputee already.’ ”

On Friday, Jan. 7, Mike told doctors to take the leg off. Surgery was the next Monday.

“I was really glad (the amputation) was less than a week away,” he says now. “If they had said they would do the operation in March, I probably would have backed out.”