Hand jive

Risk & Insurance, March, 2004 by Peter Rousmaniere

Why did Mary Beth lose her job?

I asked a hand surgeon in Charlotte, N.C., to relate this familiar tale from a composite of his patients who fail to recover from injuries. Readers, just count the times her decline might have been reversed.

Mary Beth, a 39-year-old textile worker, felt a pop in her right wrist when she lifted an 8-pound bobbin into a spinning frame. In pain, she told her supervisor the next day. He said, "Back to work!" But she could not make production targets and feared losing her job. The plant nurse had been laid off and theme was no one in the factory to help. After 10 days, the human resources director sent her to the local urgent care clinic contracted by the plant. Diagnosis: wrist sprain. Rx: a splint, Ibuprofen and light duty.

A skeptical 26-year-old supervisor put Mary Beth on low-level duties: sweeping up and emptying trash. Yet there was still no improvement in the symptoms. Mary Beth went to her personal physician, who put her off work. The HR director sent her to the local orthopedic surgeon. At her first visit the orthopedist got a positive nerve conduction test. He scheduled her for surgery on the spot and returned her to light duty work.

Adjusters were nowhere to be found, and there had been no effort to determine possible alternate causation, such as problems with the supervisor. But upon reading the report from the orthopedic surgeon, the HR director panicked and called the adjuster. The adjuster sent Mary Beth to a hand surgeon, Warren Burrows, who told this composite story to me.

The surgeon's diagnosis was mild carpal tunnel syndrome and wrist sprain. He also noted she smoked, took Xanax for panic attacks and had an attorney. The surgeon was concerned about psychosomatic and psychosocial elements to the patient's pain. He asked himself, "Does this peri-menopausal woman have pre-existing CTS irrespective of the injury? Did the injury cause the right hand to be symptomatic?" The patient said there were no symptoms before the injury, in either hand. "Can she be believed?" he wondered.

The surgeon was unclear about causation. He told her the injury did not cause CTS. What about her job? Did that cause it? The company wanted him to say "no," but the patient wanted him to say "yes." Before answering what was probably an unanswerable question, he asked for a job analysis and a job videotape. Then he ordered an MRI, which showed a small cartilage tear. This could be an old or degenerative tear. Did the pop indicate an exacerbation of a pre-existing tear? The MRI was inconclusive.

The patient continued on light duty, and her trivial work increased while the hand surgeon used medication and cortisone injections to foster some progress. The surgeon talked with the employer about improving her light duty plan, which had been thrown together by the supervisor. The surgeon came to realize that the patient's pain was more related to stress, anxiety and anger than any physical event. He took her off work to reduce the pain. It did not. She reported that she could not lift a cup of coffee. The surgeon prescribed more powerful pain medication with some ambivalence. But this was of no help, and neither was physical therapy. As a last-ditch effort and to put the CTS issue to rest, the surgeon performed carpal tunnel release. He convinced the adjuster to approve a pain specialist who diagnosed the injury as Complex Regional Pain Syndrome Type I (RSD). A series of blocks was performed, but that didn't help. The pain doctor placed Mary Beth on narcotics. The patient was now wedded to workers' comp.

Time passed and the insurer became eager to settle. The attorney agreed only if the patient were declared permanently disabled. The surgeon tried to bring closure by assigning a generous impairment rating and permanent restrictions. The patient started vocational rehabilitation and insisted on wearing a splint to interviews. No job offers were forthcoming, and no job seemed to work out. The patient disappeared from the surgeon's care.

The patient had done the math: her injury might have been the only means she had to make a living. She was well aware that textile companies were moving overseas and job opportunities for her were becoming more difficult. But did her situation have to turn out this way?

Peter Rousmaniere writes monthly for Risk & Insurance. He can be reached at riskletters@lrp.com.