how the ime comes to make a final decision about disability cases presented by dr. jeffrey hirsch...
TRANSCRIPT
How The IME
Comes to Make
A Final Decision
About Disability Cases
Presented by
Dr. Jeffrey Hirsch & Shari Altmark
Check-off List of Materials Needed for Expert to Review• Doctor’s First Report of Injury
• Treating Physicians Reports of continued care (including Kaiser)
• QME, IME & AME Reports
• Findings & Awards or Compromise & Release
• Description of Employee Duties, if signed
• Department Permanent Work Restrictions letter
Case Study #1
• Florence Nightingale
• 55 year old Mental Health Counselor, RN
•Physical Class – “2” Light
•13 years of service
•Duties consisted of:
•Psych nurse on special assignment
•Responded w/ local law enforcement to assess patients in crisis for last six years of her career
Case Study #1 (cont’d)
•Background
– Applied for SCD due to cardiovascular condition and stress
– Treating Physician’s Diagnosis:
• S/P Myocardial Infarction;
• S/Angiogram/Angioplasty
Case Study #1 (cont’d)
• Facts of Case– Not feeling well while still at work w/ left
arm pain
– Co-worker recognized signs of heart attack
– Paramedics called and transported to ER
– Diagnosed w/ MI and received cardiac rehab
– Smokes 1½ packs cigarettes a day
– No other outside factors
Case Study #1 (cont’d)
• Heart Attack/Coronary Artery Disease (CAD)
• Very credible, detailed history of occupational stress corroborated in witness statements by colleagues.
• Persistent angina after failed angioplasty of culprit lesion that caused heart attack; active ischemia proven by objective testing (perfusion scan).
• Add’l factor of Left Main Coronary Artery lesion in evolution (the “widow-maker” lesion).
Nurse Heal Thyself
• Subjective– Consistently high-stress
job
– Infarct symptoms at work
– Ongoing chest pain, fatigue, and shortness of breath
– Angina on exposure to stress
• Objective– Corroborated by job
description, history, and co-workers.
– Proven during hospitalization with subsequent angioplasty
– Perfusion scan with large scar (from initial heart attack) and ongoing ischemia
– Inherently stressful work.
Comparative Study #1
• Case #1: Bob Builder– 59 year old Park Project Coordinator– Physical Class – “2” Light– 22 years of service– Duties consisted of:
• Overseeing carpentry work at construction sites within park facilities
• Driving average of 75-150 miles per day
• 80% field/20% administrative duties
Comparative Study #1 (cont’d)
• Background– Applied for SCD due to orthopedic
injuries and pulmonary embolism condition
– Treating physician diagnosis:• “Recurrent lower extremities
phlebitis w/ complications of pulmonary embolism”
Comparative Study #1 (cont’d)
• Facts of Case– Diagnosed w/ phlebitis of left leg 3x in 2 year
period in 1998• Told due to extended driving or sitting• Recovery approx 1 month each time
– Generalized pain for 2 years but no medical attention
• Sharp pain in left lung area while driving on county business w/ trouble breathing on 6/3/04
– Drove home instead of back to office– Taken to hospital by wife– Diagnosed with pulmonary embolism
Bob the Builder meets Skeptical Doctor• Subjective
– Clinical History of only superficial phlebitis, no deep venous thrombosis.
– Applicant believed he had pulmonary embolism.
– Told of “hypercoagulability” by treating doctors.
• Objective– Very unlikely to
cause thromboembolic complications.
– Careful review of all medical records: likely diagnosis pneumonia with pulmonary infarct.
– Test to determine this disorder done incorrectly with patient on Coumadin.
Comparative Study #1
• Case #2: Francis "Ponch" Poncherello • 43 year old Deputy Sheriff
– Physical Class – “4” Arduous– 21½ years of service– Duties consisted of:
• Motorcycle patrol deputy– Investigate traffic collisions– Issue citations– Respond to calls of service– Prolonged sitting
Comparative Study #1 (cont’d)
• Background– Applied for SCD due to orthopedic
injuries, deep vein thrombosis and pulmonary embolism
– Treating physician diagnosis:• “Pulmonary Embolism”
Comparative Study #1 (cont’d)
• Facts of Case• Injured in on-duty motorcycle accident on
5/3/04– Bike went down on right side, slid 30-40 feet– Transported to hospital by paramedics
• Diagnosed with injuries to R shoulder/arm, R hip, face and 3 fractured ribs
• 14 months later swelling/pain in both legs, right worse than left and SOB– Diagnosis:
• R leg deep vein thrombosis • Two embolisms in one lung and one in the
other
Ponch wipes out
• Subjective– Right Lower ext. (LE)
trauma causes pain, damage, then swelling
– Ponch develops shortness of breath
– Pain, discoloration, and chronic swelling of LE
• Objective– Deep venous
thrombosis (DVT) proven by ultrasound
– Multiple pulmonary emboli demonstrated
– Post-thrombophlebitic syndrome creates high risk of recurrent DVT/PE, especially in prolonged seated posture (i.e., patrol)
Comparative Study #1 (cont’d)
• Compare 2 cases of “Pulmonary Embolism”
• Deputy has motorcycle accident sustaining major Lower Extremity (L.E.) damage. – Develops Deep Venous Thrombosis
(DVT) and P.E. – Has persistent post-thrombophlebitic
changes of the L.E.– Fixed Posture inadvisable
• Recommend medical disability retirement, service-connected.
Comparative Study #1 (cont’d)
• Coordinator with Parks Dep’t diagnosed with and treated for P.E. – Careful review of all available medical
records revealed more likely diagnosis of massive pneumonia with pulmonary infarct.
– Added complexity of inappropriate diagnosis of hypercoagulability (testing cannot be performed while patient on Coumadin).• Recommend return to work without
limitations.
Comparative Study #2
• Case #3: Sally Port– 34 year old Custody Assistant– Physical Class – “4” Arduous– 3½ years of service– Duties consisted of:
• Processing newly arriving inmates/searches
• Supervising inmate activity within jail environment
• Maintaining security at the jail– Direct inmate contact
Comparative Study #2 (cont’d)
• Background– Applied for SCD due to reactive airway
disease and immune system dysfunction– Treating Physician’s Diagnosis *
• Mycotoxicosis• Reactive Airway Disease• Multiple chemicals sensitivity• Chronic Fatigue Immune Dysfunction Syndrome• Reactive sinusitis and Laryngitis• Recurrent infection in acquired immune
deficiency state
* Treating doctor issue
Comparative Study #2 (cont’d)
• Facts of Case– Inmates within jail were cleaning kitchen on
other side of facility• Mixed Lime-Away, ammonia & bleach
together• Scalding hot water created vapor
– Entered A/C system– Smell of bleach permeated nearby work area– Collapsed while getting out of building– Coughing, vomiting, nose bleed– Transported to hospital
• 7 months pregnant• Diagnosed with pneumonia
Sally Port still SuperMom
• Subjective– Legitimate inhalation of
Clˉ gas/HCl.– Claimed asthmatic
symptoms prevented climbing stairs, etc.
– Described shortness of breath on many modest activities.
– Not using any anti-asthmatic inhalers.
• Objective– Chemical pneumonitis
evolving into asthma.– Mother of five with 3
young children at home.
– Under monitored conditions in office, exercised to normal level of fitness and had normal oxygen uptake on pulmonary exercise test.
Comparative Study #2 (cont’d)
• Case #4: Jane Hathaway – 60 y/o Senior Secretary III (Executive
Secretary)– Physical Class – “2” Light– 39¾ years of service– Duties consisted of typical clerical
responsibilities such as:• Answering phones• Typing/writing • Coordinating calendars/meetings for
executives
Comparative Study #2 (cont’d)
• Background– Applied for SCD due to respiratory and
pulmonary conditions, irritable bowel syndrome (IBS), esophageal reflux disease (GERD) and asthma
– Treating physician diagnosis:• “Acute stress reaction; irritable
bowel syndrome; esophageal reflux, allergic bronchial asthma; respiratory problems; joint/muscle pain”
Comparative Study #2 (cont’d)
• Facts of Case– First symptoms in 1966
• Constipation and abdominal pain due to stress
• c/o episodes sporadically for next 25 years– 1983 c/o headaches, bronchitis, SOB, and
wheezing from co-workers smoking inside building
• Diagnosed with asthma originally• 1989 diagnosed with bronchitis due to smoke
and IBS due to stress• 2003 still has respiratory and digestive
complaints• 2006 placed on medical leave due to same
complaints
Jane, Jane, stays the same
• Subjective– Stress-related
complaints with background of major psychiatric disease.
– Reportedly, problems built such that she could no longer go on
– Reported debilitating symptoms
– Didn’t believe she could work.
• Objective– Reflux, irritable
bowel syndrome, “stress-sensitive” asthma
– Records revealed three decades of similar complaints.
– Normal pulmonary function tests and GI studies.
– Did so for 30 years and still enjoyed travel.
Comparative Study #2 (cont’d)
• Robust Complaints without Objective Correlates• Young Custody Asst. with acknowledged toxic
exposure to Clˉ bleach + ammonia; had RADS evolving into asthma. Reported extreme limitations. But….– Exercised well on breath-by-breath CPET
analysis (sophisticated form of pulmonary exercise testing).
– Cared for 5 kids (four still in home and two under age 5 years).
– Used minimal anti-asthmatic medication.• Recommendation to return to work
Comparative Study #2 (cont’d)
• Older Senior Secretary with lower GI (IBS with diarrhea) and alleged work-related asthma– Was observed to require bathroom once
during almost half-day stay in my office.– Enjoys travel as a passion and
continues to travel extensively.– Terminated exercise during pulmonary
exercise test without providing reasonably adequate effort.• Recommendation to return to work
QUESTIONS ?