The most obvious are obesity, hypertension and diabetes. Due to a variety of factors including health habits, lack of family concern and financial limitations, early signs of disease are not addressed, and did not arise from injury.
However, these are not the only, or anywhere near the most, alarming situations.
Allow me to provide some very real cases from my own practice regarding the relatedness to injury:
- A 48 year old married woman sustained a severe back injury. Authorization for surgery, a fusion in this case, was delayed for greater than a year. The day after the surgery, she telephoned me to tell me of her pain status. I noted that her speech was slurred. I inquired as to whether she was taking too much medication. She stated that she was not on any medication, and she told me that she had increasing muscle weakness of her arms and legs, and problems with speech, swallowing and breathing.
The relatedness to injury was contested. She had no funds for private health care. Within months, she had died, and her cause of death was said to be from Amyotrophic Lateral Sclerosis (ALS),”Lou Gehrig’s Disease,” a progressive neurodegenerative disease that affects nerve cells in the brain and the spinal cord. Motor neurons reach from the brain to the spinal cord and from the spinal cord to the muscles throughout the body. When muscles no longer receive the messages from the motor neurons, progressive degeneration occurs.
Was there a relationship between her injury/surgery and her neurological disease? Such a relationship was denied. Could her disease have emerged suddenly the day of surgery?
This is a progressive disease that, for her, began suddenly and led rapidly to her death. Neither she nor her family had means or authority to understand relatedness or resources to seek other care.
- The patient was 43 years of age when she sustained a neck injury at work. There were numerouse delays. Her employer fired her. Her husband had health problems that precluded his working. They had no children. They had no health insurance. She told me that she was concerned about her husband, that he complained of increasingly severe abdominal pain, so severe that he would sob in pain. Without insurance, no one would examine/diagnose/treat him. She then called one morning to tell me that he had awakened her to tell her that he needed something in their barn. She found him several hours later, having hung himself. While a horrible outcome, relatedness to injury was never in question.
- The patient, at 34, had a truck driving career. He was thrown from his truck with severe facial, lumbar and shoulder injuries. Almost all care had been denied/controverted or delayed. He was often denigrated by his treating physicians because he was uneducated and told that it was not their problem that he failed to understand the nature of his problems. He told them of a small lump at the base of his neck. That lump grew to the size of a softball. Rural living, they went to a small hospital that attempted to drain the mass. The hospital discharged him without closing the hole that they had opened and instructed his sister-in-law to drain the mass for him. He had no insurance, private funds or providers that could direct him for what was becoming an emergency situation. The mass was malignant and ended his life.
- The patient was a 53 year old production worker. She sustained a rotator tear, and she had become almost immediately abrasive and suspicious about her providers and the quality of care. Her husband had elected not to work. He had married her after injury and was continually collecting documentation to assist in bolstering their settlement under workers’ compensation. She complained of severe and concerning lower GI symptoms. This was not related to her shoulder injury, and she insisted that workers’ compensation address the complaint, more out of anger than out of acceptance of boundaries under the workers’ comp system. Prior to her shoulder completely healing, she died of colon cancer.
The workers’ compensation system sets specific limits on what can be explored and treated. The most common thing told to the patient by the provider is that “this is not my area”, “I am not authorized to address this,” and/or “this is not something I can discuss with you.” What is not done is to explain to the patient that “while I cannot address these complaints, I am nonetheless very concerned, and I want you and your family to seek help. Here are some people (or facilities) you could consider.”
We have an obligation to help the patient find appropriate care even if we are not authorized to provide that care.