Tag Archives: employees

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.

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

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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