Monthly Archives: September 2010

Duty Status and the Injured Worker

At first glance, it’s pretty straight forward – sprain your ankle, don’t walk; strain your back, don’t lift or bend much; injure your shoulder, no overhead reach. All seem reasonable to the point of common sense. Ah, but there are unseen forces lurking beneath the seas of calm rationality.

The injured worker can himself be pretty conflicted. He may actually feel so much pain he doesn’t think he can work. The other extreme may also occur where he feels only minor discomfort, but really dislikes his job, and believes this injury presents an opportunity for an unexpected holiday. Most injured employees fall somewhere between these extremes. The average injury may be too badly injured to do their regular job, but they certainly are capable of doing something useful for the employer while they recover.

There are countless studies in occupational medicine literature that prove an injured employee released to light duty will heal quicker, return to full capacity sooner, and have less pain and medical expenses. This is pretty persuasive stuff. Let’s talk about why this is true.

If an injured employee is removed from the workplace, he is removed from his co-workers, who are his friends and confidants. This isolates the employee from peer pressure. If the employee is recovering at the workplace, his co-workers are encouraging him to get better. This is a strong motivating force to recovery.

The off-duty worker will also notice an evolved home life. Families figure out how to operate on less income. Maybe paid childcare can be replaced with “free” childcare provided by the injured worker parent. After these changes are made, it is much harder to motivate complete recovery from the injury.

The distraction factor also needs to be considered. Most of us know that pain is much more noticeable at night. The reason is that we are simply too busy during the day to pay much attention to pain. Work is also a distraction. While you are busy at work, you don’t have much time to dwell on your discomfort. Substitute a quiet day at home, and pain can become the center of attention and much less bearable.

A related phenomenon is how firmly you hold onto something. Conventional wisdom says you cannot let go of something you hold too strongly. When every part of an employee’s life revolves around the injury, its treatment, medications, physical therapy, home exercise programs and insurance calls, it is virtually impossible let go/get well. Perhaps a bit “Zen,” but the truth of the above occasionally becomes inescapable.

Another problem with off-duty status is de-conditioning. Often we see older workers that do heavy work five days a week. This can only continue because of physical strength and conditioning as a result of the job. Take the job away for a month or two, for any reason, the employee may find it almost impossible to return to the heavy physical job.

The off-duty status can also put up roadblocks to healing on the employer’s side. The employer will need to fill the job if the absence is prolonged. Maybe the employer will discover he doesn’t need this employee. The work situation can evolve rapidly when the employee is at home for awhile. This is much less likely to occur if the employee is at work, even in a reduced capacity.

For many reasons, accommodation of the injured worker at the workplace will almost always be helpful to both the injured worker and the employer. The worker will heal faster, return to full duties sooner and have much less chance of a long-term disability. The employer will get partial use of his employee body and full use of his mind. The employer’s workers’ compensation expense will also be reduced and his workforce normalized as soon as possible. It truly is a win-win for everyone.

Stay well,

Dr. B


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The Employment Physical in an ADA World

The employment physical is alive and well, but it’s changed in focus since Americans with Disabilities Act (ADA) became law.

In years past, the “pre-employment physical” was performed with a person’s hiring contingent on passing the exam. While the goals of this practice were good—matching an employee’s physical abilities with the job—it sometimes led to discrimination. Because of this, the pre-employment physical has evolved into the “post-offer physical.”

Despite the change in when the physicals take place, there is still a lot of value to the employer who conducts post-offer physicals. That’s because establishing a baseline physical condition is important in workers’ compensation claims. An employee’s hearing loss, arthritic back or hernia are all able to be documented at the time of a physical examination. Testing such as an audiogram provides an objective measurement of employees’ hearing. This can prevent the fraudulent claim of a pre-existing condition as a new work-related injury. With the cost of an audiogram around $20, you can do a bunch of them and still save money if only one or two injuries are prevented.

Establishing a baseline also helps quantify the severity of an injury. It can be frustrating when an employee’s back injury gets treated longer than seems reasonable. The pre-employment physical can uncover degenerative back disease and determine if the injured employee’s true baseline was morning pain and stiffness. This enables the provider to treat only the aggravation and discharge the employee when he has returned to his true baseline. All too often, the provider seems to be trying to return the employee to a condition he may not have been in 20 or more years ago. This is an imaginary baseline where there is zero back pain and the skies are always sunny.

On a more positive note, the employment physical is an investment in your employee’s health. Conditions such as high blood pressure, diabetes and heart disease can be found during this physical. The employee can be directed to get treatment for these types of conditions, preventing a heart attack or stroke in the future. At U.S. HealthWorks, our providers also talk to the employee during the physical about smoking, diet, exercise and other preventive medicine issues. Most of our centers also do urgent care, so the employee can be seen for these health conditions if they desire. We even have a reduced fee for those without insurance or primary care provider.

A relationship is established during the physical between the provider and the employee. This is beneficial if the employee needs treatment for a work-related injury. This is a valuable benefit to both the employer and employee. We make it a priority to get the employee treated as quickly and cost-effectively as possible. A good relationship with the provider gets maximum cooperation with the treatment plans from the employee. This gives the best results for both the injured employee and his/her employer.

It may sound simple, but these physicals also ensure that the employee knows where the clinic is. The excitement caused by a work injury often prevents the giving and following of accurate directions. It helps greatly if the employee has already been to the clinic. Employers have invested time and effort into picking and working with your chosen clinic and doctor. If the patient gets lost, the care will suffer.

The employment physical is a cost-effective means of preventing injuries, making sure injured employees get the right care while also keeping employers fully informed.

Until next time,

Dr. B


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Carpal Tunnel Syndrome Made Clear in 10 Paragraphs

Carpal Tunnel Syndrome (CTS) is an occupational medical diagnosis that often gives employers, patients, and sometimes even medical providers, undue levels of frustration. Like a lot of other things in medicine, reasonably simple concepts are hidden behind Latin words. You just need a basic understanding of how things are put together – in other words, anatomy.

Let’s start with the hands. The hands are absolute miracles of micro-engineering. They are capable of generating tremendous force, while being compact and delicate enough to pay a violin. They pull this off by putting the muscles that work the fingers in the forearm. These muscles are connected by cables, called tendons, to the fingers. Contract a muscle in the forearm, it pulls the cable (tendon) and moves the finger. I never fail to be impressed by the cleverness with which the human body is put together.

Because the muscles are in one place and the hand in another, the tendons connecting the two must pass through the wrist. Where they pass through the wrist is a snug fit, and therein lies the problem. The tendons pass through a “tunnel” in the wrist, made of the arrangement of the wrist bones (carpals). This tunnel is shaped like a “U.” On the sides and floor are bones, and the roof is covered by a thick, gristly strap. Through this tunnel is where 9 tendons and the median nerve pass.

These tendons and the median nerve normally peacefully cohabitate. They are probably doing that right this minute in your body. The tendons are surrounded by lubricated jackets (like a bicycle brake cable), so they slide through the wrist with ease. If the tendons should swell because the tunnel doesn’t stretch, pressure is put on the nerve, which sometimes shorts circuits.

Since this nerve supplies the thumb, index and long fingers with sensation, these are the areas that become numb. There is also shooting pains in the wrist from pressure on the median nerve.

The most important thing to realize about CTS is this is a dynamic situation. Tendons can get more or less swollen in a matter of a few days. Sometimes all it takes to reduce swelling is a wrist brace or a change of work duties. Sometimes it takes more effort involving medication (anti-inflammatories) and physical therapy. Occasionally a cortisone shot fixes the problem. As a last resort, we cut the strap (cut the gristly hood of the carpal tunnel). This allows more room for the tendons and nerve.

It is important to treat CTS sooner rather than later. Early on, it will be easier to get the swelling out of the tendons, and the damage to the nerve will be minor and completely reversible.

Why do people get CTS, or conversely, why don’t we all have CTS? There are wide individual variations on what it takes to get a case of tendon swelling in the wrist. Some people get swelling in their wrist after one month of doing repetitive work; others will never have a problem. We do know that you narrow the carpal tunnel when your wrist is in ulnar deviation. That makes it a tighter fit and probably contributes to CTS.

Ulnar deviation is bending your wrist to the side. If you are sitting at a computer, you are doing that right this minute. This occurs because the keyboard is narrower than your shoulders; so you have to bend you wrist in ulnar deviation to line up your fingertips with the keyboard. This has caused the development of “V”-shaped ergonomic keyboards, which can be very useful in treating or preventing CTS. I am using one to type this article.

 So CTS is more like a dimmer switch than a light switch. It comes in a great variety of stages. It is relatively easy to get some swelling out of a wrist and get someone healed at an earlier stage. The earlier the intervention, the more likely it will easily and quickly resolve.

Dr. B


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Does It Hurt to Get a Flu Shot?

Our own Dr. B demonstrates how easy – and relatively painless – it is to get a flu shot.  Watch:

Acute & Chronic Pain and the Human Condition

Injuries occur in all kinds of people: young, old, healthy or debilitated. The good news is almost everyone recovers from injuries. Occasionally, when a significant injury occurs in someone with extensive underlying degenerative disease, acute pain can gradually evolve into chronic pain. Acute and chronic pains are two very different animals, and the evaluation, treatment and therapeutic goals are different.

Acute pain is what we’re all too familiar with. It is usually the result of tissue damage, such as a cut finger, burn or a turned ankle. The pain usually lasts until the tissue has healed to some degree. Even this, the simplest kind of pain, is a bit mysterious. A broken bone takes several months to heal but only hurts for a couple of weeks. Acute pain is usually pretty bad – it gets your attention and makes you stop doing whatever it is that makes you hurt. That, in fact, is the point. The body is trying to limit self-destruction. The body is hard wired to take care of itself – an interesting notion.

The medical evaluation of acute pain is usually pretty straightforward. Since tissue damage causes the pain, we just need to find the damaged tissue, figure out how badly the tissue is damaged, and finally, fix the damage. I may have slightly over-simplified, but you get the idea. We treat the body part that hurts.

Chronic pain is a considerably more challenging beast. There is no new tissue damage, or no tissue damage that wasn’t there two months ago, when you weren’t in much pain. So, from a doctor’s perspective, we don’t have anything to fix. Talk about having one proverbial arm tied behind our back. The next problem is that time is not our ally. Most acute pain lessens with time; strangely enough, chronic pain doesn’t. Next month or next year is likely to hurt just as much. The persistence of pain complicates its management because all narcotic pain meds become less effective with time and continued use. That means you get less relief from more medication. Medication doses can get scarily high chasing chronic pain – not a safe or productive pathway.

So, we look at the bigger picture. For your foot to hurt requires nerves in the legs, the spinal cord and a brain to get the message. If you’ve done a lot of treatment to the painful foot without benefit, it’s time to consider the nerves or the brain. When we try to block pain at the nerve, we might try a TENS unit to block transmission of the pain signal. This is an electrical device that uses pads on the skin to block pain with a low voltage electrical field. This actually works, and unlike pain pills, if it works it will keep on working. You don’t need a bigger machine or more electricity in the future. Doing a nerve block with an anesthetic or steroid is also an example of blocking the transmission of pain at the nerve.

Finally, we look at the brain. We have all said at some point, “I’m feeling no pain.” What we meant was our brain wasn’t working well enough to feel pain (usually the result of youthful overestimation of alcohol tolerance). Feeling no pain because you are unconscious also works in anesthesia. This is an imperfect solution as it is obviously hard to work while unconscious. That has prompted the search for medications that will selectively alter pain reception without sedation.

A surprising number of different classes of medications seem to do this for many patients. One of the first medications used “off label” for pain was amitriptaline, which is a 35-year-old tricyclic antidepressant. Many of the newer antidepressants called SSRIs (Prozac, Cymbalta and Celexa) have also been used with some success for pain management. The anti-seizure medications used for epilepsy treatment are also remarkably helpful for many patients in pain. Specific examples of these medications are Neurontin and Tegretal.

Chronic pain is a different beast than acute (new) pain. Some of the best approaches involve treating the transmission of pain at the nerve or the perception of pain at the brain. If you have a chronic pain condition, there are new approaches that may change your life.

Dr. B


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Dr. Baxter Talks Flu Shots in Dallas

Our own Dr. Shiu-yeh Baxter of our Carrolton office was featured on KSKY-AM 660 in Dallas yesterday, and she even gave host Jon-David Wells his flu shot for the season. Check out a video of the show here – Part 1 (drag the dial to fast forward to 1:40:16) and Part 2.

True Tales of Finding the Fountain of Youth

For thousands of years, man has pursued the “fountain of youth.” People as well known as Alexander the Great and Ponce de Leon have wandered to every corner of the world looking for this magic fountain. Even today people continue the search.

Today we don’t expect to find it in the forest. Today we look to the vitamin store, the gym or the local plastic surgeon. I share this pursuit and have had a unique vantage point as a physician to find those who seem to have found the fountain. These are people in their 20s, 30s or 40s – people who seem to defy time. I have had the fortunate opportunity to discuss their “secret” with a number of these people by asking them their personal theory as to why they weren’t aging. Their answers are curious.

The first of these people, I met was while I was growing up. I saw him for 20 years and he remained stubbornly at age 37. He probably still looks 37. I asked him what the cause of such good fortune was. He had a theory which he was happy to share. He said, “Don’t mix up your digestion.” He had observed that people take a bit of this and a bit of that during meals. This mixes up your digestion. The proper way is to eat all of your greens at once, your potatoes by themselves, and, of course, your meat all together. I asked if the order was important, and he assured me it was not. You just had to eat each thing by itself, so as not to mix up the digestion.

Fairly early in my medial career, I met another man whose date of birth put him at 57, when he could easily pass for 30. I was still expecting he would claim a lifetime of exercise, not smoking and drinking red wine. No such luck. When I asked him what his secret of eternal youth was, he said, “Beer.” Wanting to give his theory a chance, I asked if he soaked in it, gave himself an enema with it or what. He looked at me strangely, and said, “I drink it.” I thought of my food order guru and asked if it needed to be any particular kind of beer (organic?). He answered, “Budweisers.” I asked the proper amount and he said, “About a case a day.” It seemed to work for him.

As I continued to question the genetically blessed, I found people were attributing good heath and youthful looks to almost anything other than the expected. I have met people who were convinced that eating bacon kept them in their prime. Therein lies the rub. As a society, we value youthful vigor and good looks. These qualities are widely and quite unevenly distributed. They are probably largely genetic. I think of the 90 year old who tells me it’s smoking that’s keeping him going. Sometimes someone’s gifts are even resistant to their own best efforts at ruining their heath. So we listen to the seemingly more gifted members of the human race for their advice. We buy into their theories, we buy their butt blasters, their go-upside-down contraptions and all the other “stuff” that will keep us looking young.

I am doubtful that beer or not mixing up the digestion is the real secret to eternal youth. But hearing the theories and thinking about them never fails to bring me some amusement. The real “secret” to the fountain of youth? Pick our parents more carefully!

— Dr. B


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Getting Back on the Healthy Horse

In this country, we tend to lean toward the extremes. We over eat, over drink, over spend and even over exercise. A little is good, a lot is better, so give me all.

If you ask normal people to divvy up the people around them into health groups, they assign most to minimal exercise and a few to heroic levels of exercise. The healthy among us are assumed by the others to be absolute exercise machines, to have wills of steel and unwavering commitment.

Ah, if only it were so…

I will let you in on a dirty little secret of the exercise cult. We’re just like you. We like to sleep in, procrastinate and eat too much. We have only one thing that you don’t have – and it’s what I call “get-back-on-the-horse-ness.” I don’t mean to channel the Wizard of Oz here, but the image is there. Everyone you see that exercises has quit exercising countless times. They have been discouraged, lazy, too busy or too tired like everyone else. The only difference is that we are better at getting back on a program.

A corollary of the culture of excess is high expectations, even for health. “I’m going to start tomorrow and exercise 2 hours a day and lose 5 pounds a week.” The unspoken part is: “If I can’t do the whole program, I won’t do anything.” Let’s be a little less absolutist here. It might be a bit unrealistic to expect that kind of commitment out of yourself. Maybe you don’t have 2 hours a day to exercise. You can probably swing getting up 15 minutes early and walking briskly around the block. Park a little further away, take the stairs. Small steps are OK.

We see this absolutist behavior in other health habits, good and bad. How often does someone go 2 months or 2 years without smoking, have one cigarette and jump right back up to a pack a day. One cigarette in two years is a remarkable victory. So you had one weak moment and had one cigarette? That one cigarette has zero health consequences. Smoke the darn thing, and get back on the horse.

Drinking is the same way. People with problematic alcohol consumption have a single drink after years of abstinence and immediately go on a two-week binge. Have the one drink, stop and then get back on the wagon.

I’ve had my own experience in moderating my previously extreme exercise tendencies. I had 2 low back surgeries in 3 months. I was initially quite upset because I couldn’t run or lift weights (probably not worth mentioning that the weights had something to do with the back surgery). But I found out I could rollerblade. When rollerblades became a problem, I could still walk briskly. If walking slowly is all I can do, I will do it.

So go ahead – set a low bar and surprise yourself.

Dr. B


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Working for Safety

Injuries are the sworn mortal enemy of every safety manager in the country. Many companies see zero injuries as both an achievable and realistic goal, and an opportunity for cost savings. Some companies even try to keep their injury rate low by denying there are injuries. Proactive measures generally work out better.

Let’s break down various ways to prevent injuries in the workplace:

Built-In Safety
An engineering approach to injury prevention is used whenever possible. This approach is the most sure-fire. Like the airbags in your car, no operator action is required; the safety is built in. There are many examples of this in various workplaces – non-skid matting, saw guards and electrical grounding of machines. An engineering approach is often used after an injury calls attention to a problem. It’s even better to go through the workplace with a safety expert to identify problems and look for engineering solutions proactively.

Training
The next avenue of injury prevention is training. While teaching someone to pump their brakes in an emergency stop will never be as good as anti-skid computerized breaking (an engineering fix), trained individuals will do better than untrained ones. Some work activities are inherently hazardous, even with the best safety engineering. In these instances, training and retraining are the best you can do. The more involved and participatory the employee is in the training, the better the outcome. Training needs to be designed to help keep someone’s attention (we all know what it’s like to watch those dreaded training videos). Repetition also reinforces the training. In the best model, the information is presented at intervals and in different formats to avoid loss of interest. Live demonstration is the best. Show people exactly how to do something and then evaluate how well they do it on their own; give them feedback and help them properly adjust their body to suit the task. Specialists such as U.S. HealthWorks know how to perform these critical evaluations. Ask them or other similar experts for help.

Motivation
Motivation is also used for injury prevention. Motivation, however, sometimes seems to follow the law of unintended consequence. Offering a reward for no injuries in a given month or quarter both motivates employees to work safer and to not report their injuries. On the surface, this would seem to be desirable to the employer. Unfortunately, not all injuries heal properly without care; some get considerably worse, and will end up hurting the employee and his employer much more. So, motivation is useful, but it needs to be carefully considered to avoid unintended results.

Occupational Medicine Providers
Picking a good occupational medicine provider is also useful in preventing injuries. Some injuries are minor and need little more than some evaluation (attention) and reassurance. Your provider should have the expertise to determine whether these are first aid-only visits.

Always Report
Some employers do injury “prevention” by intentionally not reporting the injury. This is not without risk in several ways. The Occupational Safety and Health Administration (OSHA) can impose some daunting fines for those who deliberately avoid reporting an injury. The untreated employee’s injury could worsen, sometimes into something permanent. That is a tragedy for the employee and can be a legal battle for the employer for years to come. Even a late reporting of an injury can cause problems when it’s finally evaluated – the claim is likely a mess. The late report calls the patient’s integrity into question by the carrier and even the physician which could result in delayed care, further compounding the patient’s injury.

Injury prevention is an active field of research. There are experts in the field that can help you safely lower your injury rate. Having a good working relationship with your employees goes a long way to getting their support in this quest. Having a doctor you trust also helps.

Dr. B


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Influenza and the Dog Days of Summer: Why You Need to Get Vaccinated

The kids are just starting school, and summer is winding down, although in many places around the country we’re still seeing heat waves. Way too early to think about flu? Not in the medical world, and here’s why.

Early last spring, scientists began planning for the 2010-11 influenza vaccine. They were looking at specific types of influenza that were circulating in the southern hemisphere. The flu seasons are offset by a half year in the northern and southern hemispheres. So often, some variation of the dominant influenza strains in the south will wreak havoc on the north the following winter.

Let me mention what the stakes are in this virus pick. In a normal year, 36,000 people will die in this country of influenza. More than 200,000 will be hospitalized for same. There are hundreds of variations of the two basic flu viruses (A and B). “A”s tend to be the most troubling, as they genetically change more often and more dramatically. If the wrong viruses are picked, things get dicey rather fast.

Having picked the three viruses, the vaccine manufacturing machine then kicks into high gear. With the combined efforts of 2 large vaccine producers and a couple of smaller companies, they design and produce roughly 500 million doses. Just think about designing and manufacturing a custom product with a short shelf life and distributing it worldwide in 5 months. Kind of makes you think differently about flu shots. They represent an immense amount of work and worldwide cooperation.

So what happens when you get a dose of the current flu vaccine? Your immune system starts cranking out antibodies against the specific influenza types contained in this year’s vaccine. It takes your body about 2 weeks to have sufficient levels of immunity to fight off an influenza exposure. Having developed this immunity, you might wonder how long it lasts. No worries. It will take you through this season and into the next year’s. The Center for Disease Control and Prevention says to get your immunization as soon as it’s available. (U.S. HealthWorks currently has the flu vaccine available. Check out where you can find a medical center near you).

All influenza viruses are made of a few genetic building blocks. That means a lot of different viruses have some common genes, so you do end up getting some protection against viruses other than the 3 covered in the vaccine. The more years you get vaccinated, the broader your immunity will be.

Many people wonder if immunity is something you can use up. Except in overwhelming infection, immunity is like exercise – the more you do, the better you are.

The influenza vaccine is one of the greatest success stories of modern medicine. It’s an example of true worldwide cooperation to eradicate this terrible disease. In the recent past, influenza killed millions. Today, this terrible scourge can be avoided with a simple shot or snort.

Dr. B


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