How The IME Comes to Make A Final Decision About Disability Cases

1. The IME Process How The IME Comes to Make A Final Decision About Disability Cases Presented by Dr. Jeffrey Hirsch & Shari Altmark

2. 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

3. 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

4. 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

5. 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

6. 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).

7. 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. Nurse Heal Thyself

8. 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

9. 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”

10. 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

11. 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. Bob the Builder meets Skeptical Doctor

12. 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

13. Comparative Study #1 (cont’d) • Background • Applied for SCD due to orthopedic injuries, deep vein thrombosis and pulmonary embolism • Treating physician diagnosis: • “Pulmonary Embolism”

14. 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

15. 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) Ponch wipes out

16. 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.

17. 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.

18. 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

19. 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

20. 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

21. 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. Sally Port still SuperMom

22. 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

23. 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”

24. 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

25. 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. Jane, Jane, stays the same

26. 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

27. 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

28. QUESTIONS ?