Indiana Worker's Compensation Institute

What are the most important components for the rehabilitation of an Orthopedic WC injury? Quick, Complete and Job Specific Rehabilitation which has historically been provided through Work Conditioning, a program that focuses on functional strengthening, aerobic conditioning and job related endurance training. However, over the past several years, Work Conditioning has declined in utilization with many carriers/physicians attempting to use Light Duty as advanced rehabilitation . Depending on the employee’s current level of physical ability, this may be an appropriate substitute. But, it may also lead to returning an unprepared employee to full duty, resulting in re-injury. To ensure the best possible outcome, it is critical for all parties responsible for an employees’ course of rehabilitation to be adequately informed on the strengths, limitations and outcome goals for both programs.

Light duty can be used in conjunction with acute rehabilitation, and as a bridge from acute rehab to full duty. A well-designed light duty program must:

– Be productive
– Be progressive in physical requirements
– Adhere to physical restrictions
– Include components that will promote ongoing strengthening of the region of dysfunction
– Allow the injured worker to incorporate stretching and strengthening while working

Light duty alone may be appropriate if: the patient is returning to a Sedentary to Medium level job class as defined by the Dictionary of Occupational Titles (DOT), has been off work for less than 1 month and has a job that does not require sustained or repetitive functional activities.

Work Conditioning is a job related, highly structured program, typically involving a daily program for 3-5 hours. The program is designed to focus on regaining the injured workers necessary strength and endurance for risk free, full return to work. Through job simulation, muscles that are responsible for maintaining posture and core stability (stabilizers) are strengthened. The program is appropriate for injured workers who:

– Are returning to a job categorized by the DOT as Medium to Very Heavy
– Work in job that does require repetitive material handling, sustained posturing or functional activities
– Have been off of work for > than 1 month and therefore are aerobically deconditioned, and present with poor core stabilization

Through Advanced Physical Therapy, program duration averages 8 visits for non-surgical participants and 15 for surgical participants.

While it is easy to see how an injured worker that is returning to a job such as a carpet installer or heavy construction may be appropriate for Work Conditioning; this program is also beneficial for individuals returning to highly repetitive jobs such as assembly line work.

Statistics have found that injured workers that participate in a Work Conditioning Program are 14 times less likely to experience a re-injury after full return to work than individuals that do not receive appropriate rehabilitation. Another study has found that individuals needing an FCE who first participate in a short course of Work Conditioning perform at a higher functional level during the FCE

As with all segments of case management, it is clear that selecting the correct components of rehabilitation is critical to a successful outcome.

On October 10, 2003 the U.S. Treasury Department announced further regulations under the Terrorism Risk Insurance Act (TRIA) of 2002 that was signed into law on November 26, 2002. This is a temporary federal reinsurance program designed to encourage the development of private sector resources and arrangements for diffusing the risk of loss to acts of international terrorism. The recent additions include the disclosure and “make available” requirements and the participation of state residual market insurance entities and state workers’ compensation funds. The Act’s authority will expire on December 31, 2005, when it is hoped that the industry will have developed a terrorism risk insurance market and methods to manage exposures. The TRIA uses a formula to reimburse 90% of covered terrorism losses exceeding the statutorily established deductible paid by the insurer providing the coverage. The limit of the Act is 100 billion dollars in any given year. To meet the definition of an act of terrorism, it must:

• have resulted in damage within the United States, (or outside the US in the case of an air carrier or vessel or the premises of a US mission or embassy).
•  have been a violent act or an act that is dangerous to human life, property; or infrastructure
•  have been committed by an individual or individual acting on behalf of any foreign person or foreign interest, as part of an effort to coerce the civilian population of the United States or to influence the policy or affect the conduct of the US Government by coercion.
• have produced property and casualty insurance losses in excess of $5M.

All of the terrorist acts of 2001 were directed towards workers in the workplace. People were not attacked at home or play. Yet only the Pentagon and World Trade Center attacks would meet the above definition. To date, the anthrax letters have not been linked to a foreign person or foreign interest. Nor would the Oklahoma City bombing of 1995 have met this definition, as those convicted were native citizens.

The World Trade Center attacks of September11, 2001 have resulted in 6,500 Worker’s Compensation claims (2,200 death and 4,100 injuries) with about 1,000 being stress-only claims. The total Worker’s Compensation costs may be 5 billion dollars. The occupational homicide death total for that year was fivefold the average year. Financial services had heretofore been a very low risk occupation. The EPA predicts that late and latent claims from asbestos, lead, cadmium, mercury, PCB’s, benzene, and chromium released from the WTC sites may be filed over a periods of decades.

Terrorism by design uses the elements of surprise, vulnerability, and stress-induction to create chaos and coercion. Bioterrorism uses unseen agents with delayed recognition and possible dissemination by human-to-human contagion to allow time for the escape of the perpetrators. Very little knowledge exists on effective workplace-based prevention or counter-terrorism, so preparedness in the workplace may be limited to training for awareness and developing disaster plans to minimize losses and confusion should an attack occur. Some up-to-date websites and references are attached.

Unlike other conflicts, there is no truce, treaty or other clear end point to the war on terrorism. It is likely that employers, workers, and the workplace will remain targets of terrorists.

Dr Daymon Evans is Medical Director of Employee Occupational Health Services for the Community Health Network, and is a part-time civilian Preventive Medicine Physician for the Department of Defense. He is board certified in Occupational Medicine, Emergency Medicine, and Public Health and General Preventive Medicine. He served on the Mayor’s (Indianapolis) Terrorism Task Force Medical Committee and is the occupational health representative to the Indiana State Department of Health Bioterrorism Advisory Committee.

Bibliography:

The Terrorism Risk Insurance Act Program of 2002
http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=107_cong_bills&docid=f:h3210enr.txt.pdf

Text of Treasury Department Press Release, October 10, 2003
http://www.treasury.gov/press/releases/js897.htm

Commercial/Organization Sites
EQECAT (catastrophic model):
http://www.eqecat.com/terrorism97.pdf

IRMI:
http://www.irmi.com/insights/terrorism.asp

Coalition to Insure Against Terrorism
http://www.insureagainstterrorism.org/index.html

Government Sites
U.S. Homeland Security. (Personal pre- and post-event planning & advice)
http://www.ready.gov

OSHA, Anthrax
http://www.osha.gov/bioterrorism/anthrax/index.html

U.S. Postal Services, Mail Center Security Guidelines
http://www.usps.com/cpim/ftp/pubs/pub166.pdf

Suspicious Mai/Package Posters
http://www.usps.com/cpim/ftp/posters/pos84.htm
http://www.fbi.gov/pressrel/pressrel01/mail3.pdf

Bombs by Mail
http://www.usps.com/cpim/ftp/notices/not71.pdf

EPA World Trade Center monitoring reports
http://www.epa.gov/wtc/data_summary.htm

Federal Emergency Management Agency
Emergency Management Guide for Business and Industry
http://www.fema.gov/pdf/library/bizindst.pdf

Book
Terrorism Insurance: What Risk and Insurance Professionals Must Know
International Risk Management Institute, Inc.
12222 Merit Drive, Suite 1450
Dallas, TX 75251
800-827-4242
http://www.irmi.com/products/bookdescriptions/terrorism.asp

No, it’s not a plain vanilla case concerning compensability.  It should cause you to look twice at many of your Indiana workers’ compensation claims.  This year the Indiana Supreme Court redefined our “arising out of” prong of the test for compensability in Milledge v. The Oaks, 784 N.E.2d 926 (Ind. 2003).

Ms. Milledge was an employee of The Oaks, a nursing home.  She was also diabetic.  One morning, as she walked from her car across the parking lot to the facility, she twisted her ankle.  There was no debris, crack, pothole, or other defect in the surface.  She did not trip over a curb or other obstruction.  In fact, no one will probably ever know why she twisted her ankle.  After she suffered the injury, she developed a blister on her ankle.  The blister became infected, then gangrenous, and finally her foot was amputated.

Because the injury occurred on the employer’s parking lot as she was preparing to report for work, there was no dispute that the injury arose “in the course of” her employment.  The employer did dispute, however, that the injury arose “out of” her employment.  Most adjusters likely would.  The employer prevailed before Single Hearing Member Linda Peterson Powell.   Not surprisingly,  the Full Board adopted Judge Powell’s decision.  Even less surprising was the Indiana Court of Appeals’ affirmation of the Full Board’s decision.   The Indiana Supreme Court granted transfer, however, and on March 14, 2003, reversed and remanded the case to the Worker’s Compensation Board, finding that the injury did, indeed, arise out of Ms. Milledge’s employment with The Oaks.

The Supreme Court discussed, and significantly altered the application of the types of risk that may result in injuries that arise in the course of employment.  The three categories of risk are:

1.      Risks distinctly associated with employment;

2.      Risks distinctly personal to the claimant; and

3.      Risks that are neither distinctly personal nor distinctly related to the employment.

Risks in the third category are known as “neutral risks.”

Relying on cases from other states, the Indiana Supreme Court held that in workers’ compensation claims that cannot be explained by a pre-existing illness or condition personal to the employee, an injury that arose in the course of employment is presumed to have arisen out of the employment.  The presumption is rebuttable, but it can only be rebutted by evidence that is within the control of the Plaintiff — her prior medical information.

The Court discussed that Indiana law does not require a Plaintiff to “prove a negative;” however, it requires an employer to do exactly that to successfully defend a claim for which the cause is not readily ascertainable if the injury arose in the course of employment.  The Court specifically referred to the “positional risk test” as follows:  “an injury arises out of the employment if it would not have occurred but for the fact that the conditions and obligations of the employment placed claimant in the position where he was injured.”  784 N.E.2d 926, 931. (emphasis in original).  The position where (and when) an employee is injured is the very nature of the “course of” element of compensability.

To take this reasoning one step further, if the mechanism of injury is not apparent, the injury is presumed to have arisen out of the employment because it arose in the course of employment.  The Milledge case significantly alters Indiana’s Worker’s Compensation law in at least two ways:

First, it shifts the burden of proof on the element of causation from the Plaintiff to the Defendant in many claims.  This overturns Milholland Sales & Engineering Co. v. Griffiths, 94 Ind. App. 62, 178 N.E. 458 (1931), which held that the Plaintiff has the burden to prove each and every element of his claim for workers’ compensation benefits.  It also appears to reverse Blevins v. Consumers Ice & Fuel Co., 129 Ind. App. 257, 156 N.E.2d 103 (1959), which held that compensability cannot be presumed in an unexplained injury if there is some evidence before the Board from which it can find that the accident did not arise out of employment.  Without reviewing the record of this case, one must presume that evidence was introduced that could have supported a finding that a blister, gangrene, and even amputation can occur in diabetic persons without any specific injury.

Second, it blends the two prongs of compensability into one.  No longer must each claimant establish that her injury arose out of and in the course of employment.  This apparently limits the application of Olinger Cosntr. Co. v. Moseby, 427 N.E.2d 910 (Ind. App. 1981) (holding that “[t]he phrases ‘out of’ the employment and ‘in the course of’ the employment have separate meanings and both requirements must be fulfilled before compensation is awarded.”)  Now, under Milledge, If the mechanism of injury is unclear, the claimant must only prove that the injury arose in the course of employment, then see whether or not the employer can prove that the injury was due to distinctly personal causes.

Milledge appears to make employers the virtual guarantors of their employees’ safety while on their premises or which traveling in furtherance of their business interests.  Because employers are limited in the information they can seek about prospective employees by the Americans with Disabilities Act, it is very unlikely that they will be able to obtain the information necessary to rebut the presumption that an unexplained injury that arose in the course of employment also arose out of employment.   Little short of legislative amendment is likely to change the law back to its previous state requiring the claimant to prove the elements of her claim for workers’ compensation benefits.

Fine wire fixators are external fixators that use tensioned wires (1-2 millimeters in diameter) passed through bone and attached to a circular frame to hold bone in a stable position for healing. Fine wire fixators have been in use since the Thirties. Difficulties with pin tract infections, joint contractures and component failures, eventually lead surgeons to abandon fine wire fixators. These problems were eventually solved by Gavril Abramovich Ilizarov, a Soviet surgeon. He started his medical career treating casualties during World War II. Like most medical innovations, the development of the Ilizarov external fixator came from necessity. Based in Kurgan, Siberia, short of supplies and treating patients with horrible battle wounds; Ilizarov found available surgical techniques inadequate. He developed a fine wire fixator, an application method and pin care regimen that solved most of the previous problems associated with fine wire fixators. He patented his method in the Soviet Union in 1951 and started the Ilizarov Institute in Kurgan, Siberia. Over the following decades, research performed by Ilizarov and other surgeons lead to solutions to many complex problems in orthopaedics that would have previously been “cured” with amputation. Unfortunately, the cold war prevented the dissemination of knowledge from the Soviet Union. It wasn’t until the early eighties that the method of Ilizarov found its way into Western medicine by way of Italy. Although the technique was appreciated by Western surgeons, the complexity of technique has limited its’ use. Over the past two decades, the fixator and method have been modified to simplify usage. Despite improvements, the difficult management of patients with this fixator has limited the indications for this procedure. Most surgeons agree that the Ilizarov external fixator is ideal for complex lower extremity trauma, correction of bone defects, and management of fracture nonunions (bones that have not healed with standard treatment).

Complex fractures are ideally treated with the Ilizarov. The fixator allows absolute control of the fracture with minimal injury to the soft tissues surrounding the bone. The soft tissue supplies the bone with its blood supply. When the soft tissue is ‘stripped’ off the bone (as occurs with plating), the bone loses some of its ability to heal. This can lead to a nonunion, which is a more difficult problem to solve. Open fractures (where the bone is sticking through the skin) have increased risk of infection, especially if plated, and are ideally treated with this method. Nonunions occur for many different reasons but often result from inadequate stabilization of the bone. Motion at the fracture site will not allow the bone ends to heal together. The Ilizarov fixator rigidly holds the bone, allowing early motion and weightbearing without risk of implant failure or motion at the fracture site.

Bone defects are often the result of a traumatic injury that has a piece of bone missing. When this occurs there are not many options; the limb can be shortened, a bone graft can be used to fill the gap, an amputation can be performed, or the Ilizarov can be used to perform a bone transport procedure. The bone transport was developed by Ilizarov as a way to treat bone defects. A shortened limb is poorly tolerated and often requires a prosthesis (shoe lift). Bone grafts of open fractures or infected nonunions have increased risk of infection. Prosthetics for amputees are expensive to produce and amputations increase the energy required for walking. Bone transport manipulates the biology of bone healing to form new bone in the area of the bone defect. A cut is made in the bone above the defect and the free piece of bone is pulled through the soft tissues at a constant rate to regenerate bone. Large sections of bone can be regenerated in this way, but the procedure is time consuming (fixator is on a month for every centimeter of bone regenerate) and painful. The Ilizarov external fixator is ideally suited for this application. This procedure is only recommended in specific situations and often an amputation may have a patient walking and more functioning sooner.

Nonunions are difficult problems to man-age. In a perfect world all bones would heal, but they don’t. Many factors contribute to the development of a nonunion; poor patient health, inadequate stabilization, and infection are most common. The Ilizarov fixator allows the bone ends to be compressed together at a constant tension facilitating bone healing. The lack of plates or screws at the nonunion site eliminates a bacterial haven and improves the chance of healing the bone in the face of an infection. The fixator can be left on as long as needed to heal the fracture.

The Ilizarov external fixator is a complex device that under the certain circumstances is the ideal solution to complex problems that continue to frustrate orthopaedic surgeons. With careful planning, application, and management; it can often mean the difference between amputation and limb salvage.

Many of us wonder about the efficacy and cost effectiveness of widespread spinal steroid injections.  In order to obtain up to date information, I recently interviewed a physician who performs these frequently.  Dr. Robert H. Dorwart, a respected neuroradiologist, is Medical Director for the Center for Diagnostic Imaging.  Dr. Dorwart is a member of the American Society of Spine Radiology, the International Spine Injection Society, the American Society of Neuroradiology, the American College of Radiology and many more respected professional organizations.  He is a recognized leader in MRI and CT interpretations as well as, in diagnostic and therapeutic procedures.  Some of the most highly respected spine surgeons in Indianapolis, IN, where Dr. Dorwart practices, utilize his expertise by referring patients for spinal injection procedures.

Dr. Dorwart stated that most of the steroid injection procedures he performs are ordered relative to the following diagnoses:  A herniated disc with or without nerve root compression, spinal stenosis, chronic disc degeneration, and a bulging disc with nerve compression.  Almost all have been classified as having chronic spinal caused pain, with imaging studies sometimes done elsewhere, confirming the diagnosis.  Chronic pain is defined as having lasting for over 4-6 weeks, and with the patient having failed other conservative treatment such as NSAIDS, oral steroids, and physical therapy.

Because the goal is to deliver the steroid as perfectly as possible to the area of inflammation and, given the normally occurring anatomic variations in patients, CT imaging is essential, in Dr. Dorwart’s opinion.  Proper placement is correlated with the imaging studies available and with input from the referring physician.  He stated the steroid only remains at the injection site for 24-48 hours and then success is dependent on the effectiveness of the residual anti-inflammatory effect .

Of the following – nerve root injections, facet injections, and epidural steroids – only the latter should even be considered without concurrent imaging.  And, Dr. Dorwart recommends ESI’s be done with imaging for more accuracy.  To support why, Dr. Dorwart quoted a study done involving only expert, experienced anesthesiologists who were asked to perform ESI’s.  They were asked to state when they were in the epidural space and then imaging was used for confirmation.  20% of the time, the doctor was not in the epidural space.  While no terrible harm is perhaps done, injecting the numbing agent mixed with the steroid, Marcaine or Lidocaine, into a vein (the most likely error made in the study) can result in no benefit and, make the patient queasy.  Inserting steroids into the thecal sac can even cause arachnoiditis.

If there is no good anesthetic (numbing) response after an injection procedure, it is not a good prognosticator of benefit.  This could occur as a result of:

-Scarring from prior surgeries.

-A disc herniation that is so large it makes absorption impossible due to blockage.

-The pain is discogenic thus, due to the tears inside the disc, which cause chemical changes and the injection has no potential for successful pain relief.

Dr. Dorwart says the “Rule of Three” is accepted best practice but he does not know the specific origin or how it evolved.  His personal criteria is the expectation that a patient will get at least 25 % pain reduction before undertaking further injections.  He suggests a minimum interval of at least two weeks.    Further, Dr. Dorwart feels the optimum success from these spinal injection procedures relies on excellent placement of the steroid, patient education (many times he is the first to provide an anatomic model or, show and explain to the patient their imaging films), and that outcome is also impacted significantly by the patient’s motivation, an issue sometimes in the Worker’s Compensation population.

In summary, Dr. Dorwart said imaging confirms the doctor is in a safe anatomic location and as close to the pathology as possible.  Currently, a universal formal treatment protocol for spinal injections is lacking, thus imaging is not mandatory.  In Dr. Dorwart’s “perfect world” he wonders if diagnostic studies done earlier to assure an accurate diagnosis, more proactive treatment involving pain relief (via injection), physical therapy and NSAIDS, might not decrease pain, time off work, result in fewer injections and avoidance of surgery except where clearly indicated.

Since the introduction of the Open MRI system in the late 1980’s, comparisons between the high field conventional systems have continued to be controversial.  Many vendors of MRI equipment have begun to place more of their R&D (research and development) monies into improving the quality of the Open MRI systems.  Today, these systems are continuing to improve and becoming more accepted in the medical community.   Furthermore, patient education has made many patients ask their physicians to use the Open MRI.  These requests are mainly contributed to the patient’s psychological needs such as claustrophobia or anxiety.  Large patients also are in need of the Open systems.

Prior to the introduction of the Open MRI, large patients were simply not scanned when the machine limitations would not make it possible.  This option has led to awareness that the healthcare system is being designed around the standard size patient.  Many of these patients are very conscious of their special needs and require a sensitive caring staff that will show them that the Open center is here for them. It has been estimated that the Open systems now make up about one third of the systems used in clinical practice.  It has also been estimated that it can be used for 90% of the imaging that is needed, and can produce, not only acceptable, but high quality diagnostic images.  However, there has been a strong prejudice in favor of the high field systems.  This discussion attempts to clarify some of the issues confronted in comparing and contrasting the high field closed systems with the lower field open systems.

Radiologists are becoming increasingly satisfied with the Open system and vendors are rising to the challenge of changing the high field bias.  Sequences are being developed that can be performed on the Open systems that were originally designed for the high field systems.  These special techniques such as fat suppression and fast spin echo, aid the radiologist in developing a differential diagnosis.  Open systems are even finding their way into interventional/intraoperative, cardiac, and neurosurgical departments.  The main debate slowing this process was the quality of the Open images.  This notion can easily be extinguished with an understanding of the physical principles involved with MRI scanning.  High field MRI techniques cannot be applied to the low field Open systems.  This practice has lead to the myth that high field strength is essential in producing a high quality MRI image.  This is simply not true.  Many factors affect the quality of an MRI image.  Proper parameter selection requires a specialized knowledge of the differences in the many factors that affect image quality.  The main trade off between high field systems and low field Open systems is time.  It takes roughly one and a half to two times longer to produce a comparable equivalent image.

One of the main factors influencing the image quality is signal-to noise ratio (SNR).  In the early 1980’s, prior to the Open systems, the main component used to increase the SNR was the magnet.  It was found that an increased magnetic field strength achieved a much greater SNR.  However, the focus has shifted to increasing the SNR with other components such as the RF (radio-frequency) system, gradient system, and computer system.  Another way to increase the SNR is with the use of surface coils.  The Open systems have an advantage in this area.  Due to a vertical vs. horizontal magnetic field, the use of a specialized coil (circular solenoid coils) allows for a further increase in the SNR values.  Open systems utilizing this technology can achieve SNR values comparable to the high field systems.  In fact, the images produced on high field systems five years ago are comparable to the routine images obtained on the Open systems today.  Moreover, many of the high field magnets in clinical practice today are five or more years old and boast superior image quality based on their field strength.

Experts, Radiologists, and educators agree, image quality is not guaranteed with a high field system.  Dr, Joseph C. George, MD, a member of the American College of Radiology, Director of Medical Imaging at The Heart Center of Indiana and Staff Radiologist at New Century Medical Imaging, states, “As a radiologist performing MRI examinations on both open and closed MRI platforms, I see the advantages and limitations of both technologies. The quality of open MRI images continues to improve, and with current technology, greater than 90% of orthopaedic and neurological studies are diagnostic.   Open MRI remains the study of choice for large and claustrophobic patients, as well as those who are anxious and may benefit by having a family member or friend present during the exam” Testimonials such as this reinforce the advancements in Open MRI which are helping to dispel the myth that High filed is better.  The diagnostic capabilities of the exam depend on the protocol selection of the Radiologist, and the ability of the Technologist to choose the proper parameters.

In the wrong hands, image quality can be greatly decreased with improper parameter choices.  The American College of Radiology has addressed this issue with the advent of their MRI accreditation program.  This program originated when Aetna US Healthcare announced they would require MRI providers to be accredited in order to receive reimbursement.  The program design ensures a standard evaluation of personnel, equipment performance, quality control, and image quality.  There is some controversy that these standards were based on the high field systems, but systems of all field strengths have passed the ACR accreditation process proving that there is no reason today’s low field magnets should have a high field bias placed against them.  The bias should be with the training and accreditation.

Another common misconception came with the introduction of the high field short bore magnet.  This magnet design, as the name implies, uses the conventional closed system design.  However, the bore of the magnet was shortened from nearly nine feet to approximately six feet including a flared patient opening to further enhance the “open” concept.  Manufacturers introduced this product in 1997 to compete with the increased patient comforts found in the Open systems.  Taller patients may find that some exams will feel less claustrophobic in a short bore, but the truly claustrophobic patients will still be unable to complete exams without some form of sedative.   Furthermore, the increase of four centimeters in diameter, which is found in most of the short bore magnets, is not quite an adequate increase for most large patients.

As you can see there are many issues involved in the choice of Open vs. Closed systems.  However, referring physicians must be educated on the advancements in technology that have allowed the Open systems to be competitive in the high field market.  High field no longer means better images; especially while Open technology continues to improve.  Quality images are the product of proper parameter and protocol selection to ensure diagnostic capability.  ACR accreditation can also be a standard indicator that an imaging facility is committed to quality, patient care, and physician satisfaction.

1.       Oldendorf, William Jr.  Open MRI assumes permanent place alongside high-field competition.  Diagnostic Imaging Oct. 1998.  MR8-12.

2.       Davis, Mark.  High- vs. low-field MR: What’s the difference.  Diagnostic Imaging Oct. 1988.  MR28-30.

3.       Wagner, Steven K.  Experts predict shift toward more power in open systems.  Diagnostic Imaging Oct. 1999.  MR2-6.

4.       Wagner, Steven K.  Vendors close differential between high and low field.  Diagnostic Imaging Oct 2000: 2-6.

5.       Wagner, Steven K.  From Glendale to Bala Cynwyd, uses for open MRI proliferate.  Diagnostic Imaging Oct. 2000: 8-11

6.       Parizel, Paul M.., DeSchepper, A.M.  Fathoming MRI physics at lower field strength.  Diagnostic Imaging Oct. 2000: 29-32.

Keith W. Smith is from Indianapolis, Indiana, and acquired his associate of Science in Radiography and Bachelor of Science in Medical Imaging Technology from Indiana University School of Medicine in Indianapolis.  He has over 13yrs experience in MRI and CT and actively holds MRI certification through the American Registry of Radiologic Technologists.  Keith has held numerous elected positions in both State and National societies for Radiologic Technologists.  He has been published in the National Journal “Radiologic Technology” and invited to lecture on many occasions.  Since 1994, Keith has been an adjunct faculty member for the IU Medical Imaging program teaching MRI and CT physics.  Keith joined New Century Medical Imaging in February of 2001 and is currently the Director of Technical Operations for their three Indianapolis area clinics.

The purpose of scar revision is to optimize scar camouflage.  A person considering facial scar revision must understand that there is no way to remove scars completely.  The goal is to improve the appearance of the scar either by disguising it, relocating it, or minimizing its prominence.  The ultimate appearance of a scar is dependent on many factors including the orientation of the scar, amount of tissue loss or injury, scar position, age of the patient, patient’s underlying health, genetic predisposition to abnormal scar formation, and technique of wound closure all contribute to the final result.

Understanding the mechanism of scar formation can be helpful in deciding on the method of scar revision.  Blunt trauma, gun shot wounds, and burn scars tend to involve a larger surrounding area of injury than surgical incision scars.  Scars resulting from these types of injuries my be less amenable to a satisfactory result or require staged revisions. Also, there are some guidelines for optimizing initial scar formation, which may facilitate later scar revision or even circumvent the need for a secondary procedure.  All scars tend to improve spontaneously after a period of maturation of one year.

Different scars require different treatments.  For example, severe burns that destroy large sections of skin cause the skin to heal in a puckered way.  As the skin heals, muscles and tendons may be affected in this “contracting” movement.  Keloid scars are a result of the skin’s overproduction of collagen after a wound has healed.  These scars generally appear as growths in the scar site.  Hypertrophic scars, unlike keloids, do not grow out of the boundaries of the scar area, but because of their thick, raised texture, can be unsightly and may also restrict the natural movement of muscles and tendons.

When a scar is of the contracture type, surgery generally involves removing the scar tissue entirely.  Skin flaps, composed of adjacent healthy, unscarred skin, are then lifted and moved to form a new incision line.  Where a flap is not possible, a skin graft may be used.  A graft involves taking a section of skin tissue from one area and attaching it to another, and time must be allowed following surgery for new blood vessels and soft tissue to form.  Z-plasty is a method to move a scar from one area to another, usually into a natural fold or crease in the skin to minimize its visibility.  While Z-plasty does not remove all signs of a scar, it does make it less noticeable.

Dermabrasion and laser resurfacing are methods to make “rough or elevated” scars less prominent by removing the superficial skin layers.  Clearly, the scar will remain, but it will be smoother and less visible.  Keloid or hypertrophic scars are often treated first with injections of steroids to reduce size.  If this is not satisfactory, the scars can be removed surgically and the incisions closed with fine stitches, often resulting in less prominent scars.

Both old and new scars can respond well to laser therapy.  The Versapulse laser is an excellent treatment for scars when they are in the vascular phase, or red or pinkish in color.  The scar will become smoother, less red, and less visible.  The CoolTouch laser can soften and minimize the appearance of the scar by stimulating collagen production.  This is the treatment for depressed scars or acne scarring.  The laser therapy may require multiple treatments, but requires no down time, minimal discomfort, and can be performed easily in the office setting without anesthesia.   Epigel sheeting is a simple, topical silicon sheeting which can be used in the management of old and new hypertrophic or keloid scars and can be used to aid in the prevention of scarring.

Insurance does not generally cover surgery that is purely for cosmetic reasons.  Surgery to correct or improve scars caused by injury may be reimbursable in whole or in part.  However, changing how a scar looks can help improve a patient’s self esteem.

Life Care Plans are becoming an integral part of estimating future medical needs.  The estimation of future medical needs is not a new concept.  In fact, attempting to predict the future is what medical-related litigation has always been about.  Formal Life Care Planning, on the other hand, is moving to the forefront as an organized method for making medically probable predictions and then using that information to set aside appropriate dollar reserves.

What is a Life Care Plan?

The Life Care Plan is an estimation or projection based on published standards of practice, research and data analysis as well as a comprehensive assessment and medical records review. Necessary information is collected by using a team approach. The estimate of needs is prepared in collaboration with each healthcare professional involved in the client’s care. The plan is unique and based on the specific needs of the individual. Issues addressed in the plan include physical, developmental, cognitive and psychosocial aspects.

The intent of the Life Care Plan is to allow the client to be as independent as possible.  The plan is a guide which ensures that funds will be available to properly care for the client throughout his lifetime. The Plan is an estimate of medical care and costs and may also include a vocational assessment. Contents of the Plan are comprehensive but can be modified according to the needs of the requestor.

Who would utilize a Life Care Plan?

For insurance purposes, adjusters use the Life Care Plan to set reserves.  In litigation, typically, a plaintiff’s attorney will retain the services of a Life Care Planner to research the financial issues of an injured client. When a defense attorney notes that a Life Care Planner has been retained, he will do the same. It is essential that a Life Care Planner be employed who has worked on both sides and has a reputation for being ethical and consistent with the type of evaluations that she performs. Once both sides have developed a plan, these plans are usually compared in a litigation setting and through arbitration, mediation or trial, a settlement is agreed upon and money becomes available to care for the ill or injured individual.

Who needs a Life Care Plan?  

Life Care Plans provide an estimate of the medical and non-medical needs of persons with catastrophic or chronic debilitating injuries or illnesses.  Any individual with a severe injury or illness with life long on-going needs is appropriate for a Life Care Plan.

• Appropriate patient referrals include:
• Chronic Pain Traumatic Brain Injuries
• Spinal Cord Injuries Cerebral Palsy
• Severe Burns Reflex Sympathetic Dystrophy
• Multiple Trauma Injuries Orthopedic Injuries
• Amputations Electrical Injuries
• Birth Injuries Toxic Exposure
• Vision/Hearing Loss Injuries HIV/AIDS
• Medicare Settlements

Who is qualified to complete a Life Care Plan?

An appropriately skilled professional certified as a Life Care Planner should lead the team of professionals in developing the Plan. Unique to the registered nurse credentialed as a Life Care Planner is the fact that according to the Nurse Practice Act, the nurse is licensed to complete a medical assessment. This fact is substantiated and recognized in a court of law. The Life Care Planner works in close collaboration with the treating physicians, therapists, vocational experts, equipment and care providers, and economists.

What is included in a Life Care Plan? 

Needed equipment, replacement schedules, and maintenance will be included in each plan and will vary according to the individual interests and use of the equipment.  The costs projections are based on interviews with suppliers, facilities, pharmacies, and other health care providers.  If the product is unavailable in the local area, shipping is included in the cost of the product.  Inflationary trends in the industry are not reflected in the costs.  An economist is consulted to determine allowances for inflationary medical care trends.

The Life Care Plan is accompanied by a narrative report that outlines activities of daily living, treatment history, employability if indicated and loss of earning capacity.

How is the Life Care Plan implemented?

Once the money is made available, it is highly recommended that a case manager be retained to implement and continue the Life Care Plan. The money must be available and guaranteed for use by the ill or injured individual whether the money is put into a structured settlement or set aside in reserves. The cost of the case manager is usually included in the Life Care Plan, therefore the expense is already paid for and available. The case manager will keep the plan in place and determine when new needs arise. A Life Care Plan should be updated and adjusted every six months or as needed based on the individual’s medical needs.

Nicki Bradley, RN, BS, CCM, DOL, CNLCP is a Certified Nurse Life Care Planner.  Please call Nicki at 800-467-7331 ext. 200  or e-mail nbradley@bradleycm.com with any questions about Life Care Plans.

Indiana, like the rest of the country, has experienced enormous growth in the number of immigrants in its workforce.  Many Indiana employers are concerned that, in spite of their best efforts to validate federally required documentation, some employees are working illegally.  But are those “employees” entitled to worker’s compensation benefits if their illegal status is  discovered after an on-the-job injury?

The Worker’s Compensation Act of Indiana mandates that employers provide medical treatment and wage replacement in the form of temporary total disability benefits to “employees” who sustain “accidental injuries, arising out of and in the course of the employment.”

Entitlement to benefits is not only predicated upon a causal connection between the injury sustained and the work performed, but also upon the actual existence of an employment relationship.  The issue of whether or not an illegal alien is or has ever been an “employee” for purposes of the Worker’s Compensation Act has never been addressed by the Indiana Courts.  However, given that the illegal alien was likely performing a service that benefited the employer and both parties presumably had a reasonable belief that an employment relationship existed, the Worker’s Compensation Board and the Indiana Courts could find that the illegal alien was in fact an employee.

If we assume that the employment relationship exists, is the employee entitled to all benefits under the Act?  The Legislature has recognized a few exceptions to the rule that temporary total disability is owed until the employee has reached maximum medical improvement.  One exception does allow the employer to terminate temporary total disability benefits if the employee is “unable or unavailable to work for reasons unrelated to the compensable injury.” [i]  Unfortunately, case law provides very little guidance in evaluating exactly what the Legislature meant with this provision, and there is certainly no case law on point regarding whether employers owe temporary total disability to illegal aliens.  However, an illegal alien is certainly “unable” to work under federal law.

Employers are governed by The Immigration Reform and Control Act of 1986 (hereinafter IRCA) during the initial hiring process.  [ii]  Under the IRCA, Congress established an “employment verification system” whereby employment is to be denied aliens who are not lawfully present or employable in the United States.  The prospective employee must present documentation such as a social security card, birth certificate, driver’s license, green card, etc, and the employer must certify on a United States Department of Justice Employment Eligibility Verification Form I-9 that it has reviewed the required documents.

Under the IRCA, if an employer hires an unauthorized alien, or the alien subsequently becomes unauthorized, the employer must terminate the employment.  Employers who violate IRCA are subject to civil and criminal penalties.  Similarly, an unauthorized alien who presents fraudulent documentation, including “any document lawfully issued to or with respect to a person other than the possessor”, is subject to civil fines and criminal prosecution.

In Hoffman Plastic Compounds, Inc. v. National Labor Relations Board (hereinafter Hoffman Plastics)[iii], a 2002 United States Supreme Court decision, the Court determined that, in spite of the fact that Hoffman Plastics violated the National Labor Relations Act, it was not responsible for payment of back wages to an illegal alien who presented false employment verification documents.  Specifically, the illegal alien had presented a false birth certificate when hired by Hoffman Plastics.

The Court reasoned that the IRCA makes it “impossible for an undocumented alien to obtain employment . . . without some party directly contravening explicit congressional policies.”  The Court held that awarding back pay to an illegal alien “would unduly trench upon explicit statutory prohibitions critical to federal immigration policy [and] would encourage the successful evasion of apprehension by immigration authorities, condone prior violations of the immigration laws, and encourage future violations.”

Although not directly on point, the Supreme Court’s decision in Hoffman Plastics can certainly be analogized to the Indiana worker’s compensation setting.  This exact issue has, however, been addressed in unreported decisions before The Industrial Commission of Ohio.

In the case of Marcos Hernandez[iv], the Commission vacated an award of temporary total disability in an otherwise compensable claim, finding that “claimant acknowledged that he was an illegal alien during his entire tenure with the . . . employer.  Inasmuch as federal law precludes the employment of illegal aliens, claimant had no right to any income. . .”  Both employee and employer would violate the IRCA if temporary total disability benefits were paid, opening the door to civil and criminal penalties.   Similarly, an illegal alien’s inability to work in the United States likely renders them “unable or unavailable to work for reasons unrelated to the compensable injury” under the  Indiana Act.

A fraudulent misrepresentation argument might also be made.  Again, no Indiana cases are on point, but Virginia has addressed this issue. In Granados v. Windson Development. Corp., et al. [v], the Virginia court affirmed a denial of benefits, because credible evidence established that plaintiff misrepresented his ability to legally work at the time of hire, the employer reasonably relied on the misrepresentation and that, but for his hiring, plaintiff would not have been injured in the course of his employment.  Plaintiff sustained an on the job injury, and the employer subsequently discovered that plaintiff had misrepresented his documentation.  Plaintiff’s inability to work in the United States was not corrected. The court further reasoned that the employer complied with its obligations, and the claimant should not benefit from his fraudulent procurement of employment.

Given that the Indiana Act’s provision allowing termination of temporary disability benefits is somewhat unique, there are few, if any, decisions from other jurisdictions addressing this issue.  Most other decisions turn on the issue of whether an employment relationship actually existed in the first place.

The issue of whether an employer can properly terminate temporary total disability payments to an illegal alien was recently decided by the Full Worker’s Compensation Board on appeal from a Single Hearing Member’s Award.  In that case, an employee presented an invalid social security card to the employer when he was hired.  That faulty documentation was discovered after the employee sustained an otherwise compensable work-related injury.  The Full Board found that the employee’s “lack of a valid social security number caused him to be unable to work for reasons unrelated to his injury” and further, that the employer properly terminated temporary total disability benefits pursuant to the Worker’s Compensation Act.  That decision is on appeal to the Indiana Court of Appeals, so a final answer to this question will not be had for some time.

The Worker’s Compensation Act is silent on whether medical benefits can be terminated along with temporary total disability if an employee is “unable or unavailable to work for reasons unrelated to the compensable injury”. Likewise, the United States Supreme Court did not address medical benefits in Hoffman Plastics.  But, given the “humane purposes” of the Act, the Worker’s Compensation Board and the Indiana courts could find that illegal aliens are at least entitled to medical treatment for on-the-job injuries until the point of maximum medical improvement.  Payment of medical benefits to illegal aliens was not at issue in the case recently decided by the Full Worker’s Compensation Board and is not on appeal to the Indiana Court of Appeals..

Due to Indiana’s unique statutory provision, illegal aliens are likely not entitled to temporary total disability benefits, because Federal law renders them “unable” to work here in Indiana.  A contrary decision would put employers in the no win position of choosing between complying with Federal law or paying wage replacement temporary total disability benefits.

While awaiting a final determination on this issue, what can an employer do to ensure that it is complying with both Federal and State law?  There are “social security validation” services which can double check that the employee’s number is valid.  In Worker’s Compensation claims involving employees who have some language barriers, it’s also advisable to assign a nurse case manager and translator to manage the medical aspects of the claim and to maintain communication with medical providers.  Although, the Indiana Worker’s Compensation Board does not have translators on staff, it can provide some resources for both the employer and employee regarding its rules and requirements.  Additionally, a new Mexican Consulate office has recently opened in Indianapolis to assist immigrants.

[i] I.C. 22-3-3-7(c)(5)

[ii] 8 U.S.C. §§1324

[iii] 122 S. Ct. 1275 (2002)

[iv] The Industrial Commission of Ohio, Claim Number 96-606492

[v] 480 S.E. 2d 150 (Va. Ct. App. 1997)

Recently, the debate over which is better, “high field” or “open” MRI systems was brought up. What is peculiar about the renewal of this argument is that it is over. In fact, it was over long ago. A recent trade publication noted that in excess of 60% of all M.R.I. systems being sold today are of the “open ” variety.   In fact many local hospitals, historically exclusive users of “high field” or “closed” systems, are today exclusively using open systems.  In an effort to educate our clients, Midwest Diagnostic Management (MDM) sought the expertise of Norman Pennington, M.D., of Midwest Medical Imaging, to comment on the advantages and disadvantages of both systems.  The highlights of Dr. Pennington’s comments are offered below.

There is a reason for the popularity of open systems. They are able to accommodate just about any type patient, while providing a maximum of comfort with little, if any, sacrifice in the quality of the images they produce. In days past, manufacturers emphasized that quality was strictly related to the strength of the magnet involved. However, as technology has progressed, the major advances have been in the computer hardware and software used to generate those images. Thus, the only real power to be concerned with is the ability of the computer analyzing the signals one gets from the MRI scanner.

There are some advantages to utilizing a high field system. They can save on the order of 5 to 10 minutes out of an hour on some scans. This may be helpful if you cannot hold still, are in a great deal of pain, or had a recent stroke.  However, it is equally important to point out that a larger patient or patients who are claustrophobic may not do well in the smaller confines of a closed machine.  For these types of patients there may also be a higher cost associated with completing their test in a high field system.  These additional costs often come in the form of sedatives or, worst case scenario, a second test in an open system should they not be capable of completing their test in the more uncomfortable closed system.

Both types of systems have the ability to produce excellent quality films, as well as poor quality films.  The keys to a successful test lie in selecting a system that a) best meets the physical needs of the patient, b) is run on updated hardware and software and c) is operated by quality technicians who are extensively trained.  Midwest Diagnostic Management takes all of these factors into consideration when scheduling your patients for a diagnostic procedure.  In fact, this process starts well before your referral is received, by only contracting with providers of diagnostic services who pass a rigorous credentialing process that takes into account their operating systems and technician and/or radiologist training.  Combine the highest quality network with superior customer service and reporting capabilities and you are left with Midwest Diagnostic Management as the country’s premier diagnostic referral management service.

To learn more on the “open versus closed” MRI debate or Midwest Diagnostic Management’s ability to serve all of your diagnostic referral needs, please call us at (800) 331-6062.