Category Archives: Occupational Healthcare

The Placer (Calif.) Herald: Sun can pose long-term danger to outdoor workers

By Dr. Donald Bucklin, U.S. HealthWorks

June 9, 2011

With the summer and its heat approaching, almost everyone will be out in the sun more than they were during the winter.

Sun Poses Long-Term Dangers to Outdoor Workers

By Dr. Donald Bucklin

With the summer and its heat approaching, almost everyone will be out in the sun more than they were during the winter.

For 9 million Americans, being outside and in the sun is not just for summer fun – it’s a part of their job.

Workers in farming, landscaping, construction, recreation and even postal workers will spend hours in the sun – and consequently be exposed to potentially harmful levels of ultraviolet radiation.

Working in the Heatphoto © 2011 | more info (via: Wylio)Ultraviolet radiation, and specifically UVB, is the main environmental hazard to the outdoor worker. Most workers’ shifts include the peak intensity hours of UV exposure – 10 a.m. to 2 p.m. Since this type of radiation, UVB, easily penetrates clouds, it can reach worrisome levels even on days where little sun is visible. It easily passes through glass and can be reflected into areas of apparent shade.

UVB penetrates through the tough, dead outer layers of skin, into the replicating layers. It is there that it interacts with the living tissue, not entirely in a negative fashion – UV radiation on unprotected skin produces Vitamin D. Many believe, and there is some evidence to back it up, that there are anti-cancer properties in this potent antioxidant vitamin.

But radiation on living tissue also has a biologic cost. UVB radiation causes DNA damage and is officially listed as a carcinogen. This damage is cumulative. Ultraviolet radiation and skin cancer share a similar relationship to that of cigarette smoking and lung cancer. According to the Skin Cancer Foundation, those who work outside are twice as likely to contract skin cancer as indoor workers.

To protect workers from this hazard, we need to reduce the dose of UVB radiation.

The obvious solution for employers is to instruct workers to avoid sun exposure and seek shade when available. When possible, employers can rotate or stagger work shifts so that employees spend less time working during the sunniest parts of the day.

While the suggestion that people wear long-sleeve shirts during high temperature periods usually is greeted with derision, in fact there are a variety of new fabrics with high Sun Protection Factor values that are light weight, breathable and durable.

One of the oldest fabrics, cotton, has long been recognized for its skin protective value in the hottest climates. Cotton long-sleeved, loose-fitting shirts and pants, and broad-billed hats are some effective clothing options for outdoor workers. In dry climates, the fabric actually soaks up sweat and is an effective evaporative cooler.

Sunblock provides UV protection, but the level of protection is almost universally overestimated.

The most common error people make is using high Sun Protection Factor, sweat-proof sunblock and applying it only once. Sunblock generally loses effectiveness after about two hours due to sweating, the friction of clothing and deterioration due to sunshine. And too often, too little is applied. An ounce is recommended to get advertised protection. But remember, sunblock isn’t “liquid shade.”

These common sense protective measures can help safeguard you and your employees year round, but particularly during the summer months when, in most parts of the country, exposure to UVB radiation is highest. With awareness and a few simple steps, we can help workers avoid the short-term sting of a sunburn and the long-term consequences of too much sun exposure.

Occupational Medicine at Work

We recently asked our providers to share stories about their experiences in providing care at U.S. HealthWorks. We thought this piece from Dr. Alix Thorson, Managing Physician of our Lynwood, WA, clinic, provided interesting insight into some of the work-related injuries she has seen at U.S. HealthWorks. Names have been changed to protect patients’ privacy.

When an individual gets injured at work, we at U.S. HealthWorks understand that this can be a vulnerable, unpredictable and painful time in the patient’s life. This is often compounded by an uncertain economy, with jobs in the balance and companies struggling. Can U.S. HealthWorks make a difference in these patients’ lives, as well as the health of their companies?


Nothing will take the place of excellent medical care and genuine empathy, but U.S. HealthWorks goes a step further by providing a level of occupational expertise critical for these patients and their employers.

Over the last seven years as a physician at the U.S. HealthWorks clinic in Lynwood, Washington, numerous examples come to mind:

Early Intervention and On-Site Help
In the spring of 2009, Frank came in with a back injury, suffered while lifting a case of soda. His back spasms were so severe that he was doubled over in pain and unable to straighten up. We fast-tracked him that day for a chiropractic adjustment, as well as physical therapy, and soon thereafter he was able to drive home much relieved. Frank was evaluated the following day by our physical therapist, and it was obvious that his early intervention and therapy accelerated his recovery and return to work. This shows how fortunate we are to have on-site physical therapy, chiropractic care and massage therapy. Our focus is not only on acute rehabilitation, but also on returning workers to their jobs quickly, safely and with a lower risk of injury recurrence.

A Helping Hand
Salvador, a Spanish-speaking patient, came to us with a nail embedded in his left hand that occurred while he was installing a roof. His trusting eyes could not conceal the fear of losing the use of his hand and his livelihood. As we guided him through his x-rays, injections and wound management, he was reassured with the help of our experienced Spanish translator. He was back to full duty after only a week, and we were thankful that we could provide skilled, efficient and cost-effective treatment for his injury.

Understanding Workers’ Compensation
Then there are patients like Greg, who suffered from a severe eye injury after being struck by a rock at work. He required same-day emergency care and multiple specialist follow ups. His claim, however, was subsequently rejected on a technicality. Thankfully the situation was later corrected, as was his vision. Intimate knowledge of workers’ compensation laws and communicating with claims managers and company contacts are things that greatly benefit our patients and their employers.

Getting Back to Work Safely
Thanks to our relationship with hundreds of companies, we were able to help patients like Louis, a laborer whose wife was expecting a baby in the same month as his injury. He was facing a loss of income after he fell off a truck on the job, but once we contacted his employer per our usual protocol, we were able to discuss his injuries and an appropriate modified position for him. He started a light duty job with his employer the next day. Louis, like most of our patients, was able to work and continue treatment of his injuries simultaneously, resulting in improved short- and long-term outcomes for him and his company.

U.S. HealthWorks provides outstanding occupational care, and that can make a difference to the hardworking people that need our help. Rewards in my position are many. I count among my favorites the firm, thankful handshake of Vincent, a landscaper whom we discharged after successfully returning him to his job from a serious knee injury. He left our clinic trailing fresh dirt from his work boots and a big smile on his face.

Sunshine 101

Summertime. The kids are off, the pool is warm and the sun is working overtime, at least if you live in Phoenix, Arizona. I daresay we may very well be the sunshine capital of the country. Our newspapers don’t list minutes of peak sun exposure to sunburn – we list seconds. Perhaps a bit of an exaggeration, but we know sunshine in the desert.

Before we get into the latest anti-aging/fountain of youth/magic sunblock, we need to talk about sunburn a bit.

The sun is a great big natural nuclear reactor up in the sky. Interestingly enough, the earth quakes (sun quakes) and tidal forces on the sun are literally off the Richter Scale, but the sun seems to tolerate them and should for a couple more billion years. The sun puts out radiation that they don’t make sunblock for, but by the time that radiation reaches earth, it has been reduced in intensity about 10 zillion percent. What is left is a mixture of X-rays, ultraviolet, visible light and infrared (heat) radiation. Most of the X-ray radiation is dispersed in the atmosphere. We are big fans of the visible and infrared radiation (think of a lizard sitting in a sunbeam). The ultraviolet we deal with less elegantly than the infrared.

sun shadephoto © 2007 .D.B. | more info (via: Wylio)

Ultraviolet light is broken up into 3 kinds – A, B and C. They do this to confuse people and make it seen complicated. UVA is the closest to visible light; it passes most easily through the atmosphere and won’t give you a sunburn. UVA is used in tanning beds and photo therapy. Photo therapy is when you go to Hawaii because you’re depressed (and try to deduct it as a medical expense).

UVB is shorter and higher energy. The ozone layer absorbs much of it, but we get enough at the surface to still get a pretty good sunburn. UVC is entirely absorbed by the atmosphere, and a good thing too, because it is germicidal and could wreak havoc with the microbes and ecology of the world – not to mention, you could watch your skin age.

The problem with ultraviolet radiation is it damages the skin. Excessive exposure over a short time results in the well known sunburn. This is a first-degree burn to sun-exposed skin. Anyone who has ever had one can appreciate just how much skin you have. It’s the largest organ on the body, and it is well supplied with nerves, particularly pain fibers. Hydration and ibuprofen are the way to go with the usual sunburn. A really severe sunburn needs hospitalization with IV hydration and serious pain meds.

But skin is damaged by sun exposure, even if there is no visible sunburn. Ultraviolet radiation penetrates surprisingly deep into tissue, damaging cellular DNA and elastin. DNA damage is usually repaired successfully by healthy cells. Rarely, the cell is repaired incorrectly but goes on and multiplies. We call that cancer.

UV radiation also breaks down the elastin in the skin. The elastin gives the skin its tone and support. Damage to the elastin leads to premature wrinkling and aging of the skin – a fate worse than death, according to some.

Sunblock is a recent development in society and has become an essential accessory on the equipment list for outdoor activity. There is little doubt it is generally effective at lowering UVB dosages, which reduces the more common kind of skin cancer and skin aging. Beyond that, sunblock is widely misunderstood. When was the last time you read the instructions on a sunblock bottle? Although it is counterintuitive, it doesn’t block the instant you smear it on. We think of them as paint. Smear them on and instant shade. They actually bind with elements in the skin to become effective. This takes time. In general, sunblock needs to be applied 15 or 20 minutes before sun exposure for peak effectiveness.

Then there is that whole Sun Protection Factor (SPF) number. There is a complicated formula to calculate the protective value of a sunblock. I have been known to stand in front of the sunblock display and carefully consider my outdoor activity and which to buy among 15 different brands, claims of waterproof/sweat proof/anti-aging and SPFs from 15 to 60. A frustrating experience and a waste of time. Buy your favorite smell, nicest bottle or least expensive as long as the SPF is 15 or greater.

The SPF factor is almost irrelevant. The SPF value of your sunblock is the least important ingredient in whether you get a sunburn. The dirty truth: sunblock only protects you for about 2 hours. Sunblock loses effectiveness with time, water, sweat, dirt and sun exposure. If you apply SPF 15, you will block about 90% of UV radiation for 2 hours. If you apply SPF 50, you will block 95% of UV radiation for 2 hours. After 2 hours, you are on your own. High SPF numbers wash, sweat and bake off just as fast as low SPF numbers. You really can’t get longer protection from higher SPF numbers.

The next common sunblock operator error is not using enough. Too thin of a layer will not protect you fully. That means you need to use an ounce. What is an ounce? Fill up a shot glass. That’s a lot of sunblock!

Sunblock also has an expiration date on it. Don’t count on full 2-hour protection if the bottle is expired.

Keep in mind, that the best sunblock is not portable shade. It is hard to beat shade. There is a reason the outdoor workers in Phoenix wear long pants, long-sleeve shirts and hats, even in the summer. Clothing does not lose its SPF factor for years. You can even be one of those funny people who carry umbrellas on sunny days when shopping.

Summertime is a great excuse to be outdoors doing active, fun things. A little preparation will allow you to avoid a sunburn and play another day.

Take care,

Dr. B

What It’s Like To Be a Provider at U.S. HealthWorks

We recently asked our providers to share stories about their experiences in providing care at U.S. HealthWorks. We thought this piece from Dr. Donna Diziki, Center Medical Director of our Edison, NJ, clinic, was a great example of what’s it like to practice medicine and be part of the U.S. HealthWorks team.


The word conjures up images of sweaty men on chain gangs hammering railroad ties.

Life’s work.

Now that image is quite different in your mind’s eye – sunshine on a flowering meadow, commitment, fulfillment.

But how do you merge these two visions?

As physicians, we must decide our paths early on in our training. Sometimes this path has no exit or detours, such as choosing to be a surgeon, and we follow the colleagues before us. With these career choices, there is little control over the work; rather, the work steers the provider.

Others have the luxury of career options and ways to broaden the spectrum of their training. In my opinion, these are lucky ones. These doctors can venture down alternate routes on their career paths and find amazing destinations where fulfillment and growth are possible and encouraged.

Not all of us are meant to be solo providers, so the tricky part is finding a place where one can practice medicine in a meaningful way and be allowed to grow in a position. How do you find such a place?

U.S. HealthWorks has given me that elusive blend of a fulfilling medical practice coupled with an opportunity to fill my need to develop new skills in the areas of management, business practices and marketing. I joined the company hoping to be able to have a little control of the daily running of a medical office without the financial burden of opening my own clinic. What I have found is a company that encourages me to push my boundaries to make our collective futures successful.

The Managing Physician program at U.S. HealthWorks allows the participating physicians to play a vital part in the management team. It is a reflection of the company’s commitment to support physicians, and it enables them to be professionally successful. The program empowers me to learn new skills, innovate new policies and motivate staff. U.S. HealthWorks offers me the tools I need to lead and flourish in both the business and medical arenas. When the local centers are successful, the company is successful.

I have the utmost respect for the employees of U.S. HealthWorks. How many companies would entrust a physician with operating a medical office where the only rules are “Do your best” and “We will give you what you need to succeed”? They have the faith that the physician will perform to his or her potential, and the company will assist in areas that need cultivating. We have open access to upper management at all times – this awe-inspiring fact makes U.S. HealthWorks a truly unique place to work.

There’s that word again. Work. Some days it feels like the chain gangs are toiling on the railroad. But most of the time, working at U.S. HealthWorks is more in line with what I see as my life’s work: working for a company committed to our mutual success, fulfilling my needs as well as the needs of those we serve.

Delivering Care in All Situations

U.S. HealthWorks' Dr. Cori Repp

We recently asked our providers to share some stories about their experiences in providing care at U.S. HealthWorks. We thought this piece below from Dr. Cori Repp, Center Medical Director of our Bradenton, FL, clinic, was a great example of the diversity of experience as U.S. HealthWorks provides the care our patients need every day.

“Doctor, you’re not going to believe what you’ve got in Room 2.”

I looked up from my chart to see Mary shaking her head.

“This woman was assaulted last night,” she said.

I walked into the room and introduced myself. The patient was an older lady, with a slumped posture. She was visibly upset and had multiple bruises on her legs.

“Please tell me what happened,” I said.

“I was attacked,” she cracked a faint smile, “by a rooster! I’m worried that it has the rabies. I don’t want to get the rabies.” She confided to me in a soft drawl. “I hear it makes you crazy.”

She was actually the second patient attacked by the same rooster. It wasn’t at a farm or a processing facility but in the wooded, scenic garden of a nursing home, where she worked. It took longer to convince her that she wouldn’t get rabies from the bird than it did to treat her wounds.

As physicians, we look forward to challenges that keep our careers fresh and exciting – and keep us on our toes. In our occupational medicine clinic at U.S. HealthWorks, you never know what to expect behind the exam room door.

Occupational medicine is a rewarding field centered on the care of injured workers. Many physicians talk about their love for the field of medicine but express disappointment with the actual practice of it. Not at U.S. HealthWorks. Being part of a dynamic company with one focus greatly improves a physician’s ability to concentrate on the most enjoyable part – patient care.

Our case closure evaluation system is based on choosing the right tools to quickly return the worker to full function. Doctors are encouraged to provide appropriately intensive care to decrease the overall time for an injured worker to recover.

The diversity of occupational injuries keeps even a routine office day from being mundane. When a dog chases a delivery person into a canal and bites him, a provider has to put some thought into antibiotic coverage spectrums. Even routine musculoskeletal injuries become less repetitious when you consider the stories behind the cases. Wrist contusions are common, but how many occur from being squashed under a manatee when the chunky fellow rolled suddenly? I’ve seen three, all caused by the same animal.

U.S. HealthWorks encourages physicians to get to know the companies whose injured workers we treat. We visit companies that are household names, getting a backstage tour to see where the magic happens. I have toured the factory where Chris-Craft boats are born. I saw the entire process that turns Florida oranges into globally shipped Tropicana orange juice. I’ve even been to the nursing home where my patient lost a fight with that territorial rooster.

We treat those who assist us – firefighters, police, EMTs and teachers – when they are hurt in the line of duty. It’s rewarding to feel like an important part of your community.

Every day another exam room door opens to present a new challenge. Working for U.S. HealthWorks provides a variety of opportunities to practice occupational medicine that is as diverse as the businesses we serve.

Dr. Bucklin: Radiation and Your Health on FOX Phoenix

This morning, our own Dr. Donald Bucklin appeared on KSAZ-TV (FOX Phoenix) to talk about radiation’s effects on health.

Check out his interview here

Dr. Bucklin Offers Insight on Radiation Exposure to CNBC, Wall Street Journal

In the wake of the nuclear disaster in Japan, U.S. HealthWorks’ Medical Review Officer Dr. Donald Bucklin appeared on CNBC‘s “Squawk on the Street” this morning to discuss what health effects, if any, there might be following the explosions. Check out his interview here, as well as his thoughts in the Wall Street Journal and Bloomberg.

Urine Drug Screening 101

Pre–employment drug testingphoto © 2011 Francis Storr | more info (via: Wylio)I see a lot of drug screens. As the National Medical Review Officer for 36,000 companies, I spend a lot of time answering questions about them. The most frequent category of question involves the numbers seen on positive urine drug screens results. I will review what these numbers mean and what they can and cannot tell you. I will try to clear up the cloudy urine, so to speak.

We’ll start with cut off levels. There is a simple concentration level that determines the “line drawn in the sand.” Any value equal or above the limit is positive, and those below the limit are negative, kind of like Black Jack.

Now to complicate matters, every positive drug screen goes through two different testing procedures. The first is called an immunoassay – this test is highly sensitive and not very specific. They can detect several variations of a drug (drugs break down into several parts in the body). In the case of marijuana, the cut off of the immunoassay is 50 ng/ml. Either the test is positive (above 50 ng/ml) and goes on to further testing, or it’s below 50 ng and is reported as negative. There is never an immunoassay numeric result.

Any positive initial test (immunoassay) will undergo a second testing of a different type-GCMS confirmation. This stands for Gas Chromatography Mass Spectrogram (don’t worry – there won’t be a test later). This is an extremely specific test that identifies one single drug variant in the urine. Because it identifies a single molecule type, the cut off level is low, 15 ng/ml in the case of marijuana. The GCMS result is the only number reported. The lab reports the test as negative if it is below 15 ng/ml. If it is above 15 ng, a quantitative number is given, like 38 or 300.

That is a lot to write down, but we are just talking a cut off level. We see cut off levels everywhere in life – 90% in school gets you an “A,” 89% a “B.” Driving 75 mph on the highway gets you there, while 80 mph gets you a ticket.

So, let’s say we have a drug screen that is positive for cocaine at 300 ng/ml (the cut off cocaine is 100 ng/ml on GCMS). Every day a company wants to know if the donor was under the influence at the time of the drug screen. The simple answer is: “I have no idea.”

That information isn’t available with a urine drug screen. The reasons are several. The most important is the concentration of drug in the urine is not the same as the concentration of drugs in the brain. Drugs in the urine don’t affect you; drugs in the brain do. The other reason a drug screen won’t reveal impairment is there are too many variables (unknowns). Among these are the donor’s dose, timing, body weight, food and drink intake, kidney and liver function. All affect the level of the drug in the system. So for a given value in urine, the donor could have arrived at that by taking hundreds of different combinations of drug amount and timing before the drug screen. So we can say the cocaine was definitely present in the urine, and it was a positive drug screen. The positive result cannot tell you if the donor is a long-term cocaine user or used it once in his life right before the drug screen. And it can’t tell you whether he was impaired (high) at the time of the drug screen.

So a urine drug screen only places the person into a user or a non-user group. We unfortunately don’t have chronic users groups and tried-it-only-once user groups to pick from.

– Dr. B

Physical Therapy: The Medicine that Cures

When people are injured, it’s important to as soon as possible restore function and movement to some reasonable form.

Everyone is eager to get back to their life, job or recreational activities, but the pain of injury is difficult, disruptive and discouraging to one’s normal activities. And the longer the injury drags out, the more likely depression will ensue.

The ticket to success in overcoming an injury is early mobilization. But this has to be done within reason, with patience and with an understanding of the body mechanics relevant to the injured body part.

The plan tailored to the injury and level of conditioning is the physical therapy. It remains the cornerstone of recovery and preventing further injury. Coaching by a physical therapist is critical to planning the recovery and doing no further harm. A good plan and continued mentoring by the therapist will ensure a speedy recovery.

www.Army.milphoto © 2008 The U.S. Army | more info (via: Wylio)

The basics of therapy during the initial acute phase are well known: rest, ice, compression and elevation (R.I.C.E.). Early mobilization of the injured part within reason, as well as the rest of the body, is beneficial. It continues to maintain muscle tone, which starts to atrophy after 24 hours of inactivity. The additional weakness and stiffness needs to be minimized rather than creating an additional liability. Essentially, increased circulation helps promote healing.

Convalescence from a significant injury is often frustrating and has its ups and downs. During the recovery phase, it’s key to remain within certain boundaries to avoid over-training.

Nonetheless, several variables have to be monitored by a physical therapist and your healthcare provider to stay on course. Recapturing strength, endurance and range of motion are the goals for recovery. Although some common patterns emerge for certain injuries, we are all individuals who bring different considerations to the challenge. We often think of these as baby steps to recovery.

When the pain of the acute phase subsides, typically there is weakness that remains. Getting back to a functional level of activity can take more time than you wish. Listening to your body is important. Also, using the expertise of the physical therapist and maintaining an open dialogue with the therapist will get you to your goals as soon as possible.

Remember, it does take time to regain your normal level of endurance. Along the way, learning the best body mechanics for your activities, and getting and maintaining a level of strength suitable for the job are critical to getting better and staying that way. Physical therapy is the medicine that cures.

– Dr. Bruce Kaler