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You’d think that Adventist Health, you know that religious, hospital/healthcare corporation would do everything in their power to ensure that their employees who suffered a work-related injury would get care in a timely fashion. Unfortunately, that’s not been my experience, especially with what should’ve been my final surgery.

As I posted yesterday, I suffered a full respiratory/cardiac arrest just as the anesthesiologist gave me a nerve block. More than four months later, I’m still waiting for the follow-up care required after such a life-threatening event; but this delay shouldn’t come as a surprise since Adventist Health did nothing to get the medical clearances needed for my shoulder surgery.

After having to go to court to get the Adventist Health to approve my right shoulder surgery, I discovered that Ms. CA decided that before giving the surgeon the go ahead she had to run it by utilization review (UR), in case UR paper-pushers could find a “way-out” of having to provide the very surgery that Adventist Health had agreed in court to provide, I guess. UR, however, green lighted the surgery, including the hematology consult requested by the surgeon. So after this unseen delay, it fell to my daughter and I to make all the necessary appointments to get the requisite medical clearances.

Medical clearances are part in parcel prior to surgery and this is a generally accepted medical practice and standard of care Ah, but not so with Adventist Health. After scheduling the same hematologist that Adventist Health had used for an earlier clearance, I learned one day before my appointment that Ms. CA had denied the clearance. Not only did she deny the approval she told the hematologist’s assistant that my right shoulders wasn’t part of my Workers’ Compensation claim. So with the clock ticking and thanks to the help of Keck-USC where the hematologist practiced we were able to get my private healthcare insurance to cover the consult. Of course the whole point behind Workers’ Compensation is that your employer’s workers’ compensation insurance pays for all the care, direct and related, of the injured worker. Perhaps this isn’t the case with Adventist Health?

To be continued . . .

You’d think that if you surfer a life threatening emergency while undergoing a surgical procedure you’d think that your employer’s Workers’ Compensation insurer carrier wouldn’t question your surgeon’s medical decision – but that didn’t happen in my life-threatening moment. Here’s what happened.

After several years of going back and forth with Adventist Health (who’s self-insured) to get them to approve surgery on my right shoulder I finally got the green light. This process had been very contentious and time consuming, but on August 17th, I arrived at the “hospital” to have my surgery. All was going along as planned until just after the anesthesiologist performed a nerve block. I almost immediately began to experience problems breathing and informed the operating team that I was having severe chest pains and couldn’t breathe. And as they say “all hell broke loose”. I remember the anesthesiologist screaming “I need help over here” and I asked God to please let me live.

I awoke sometime later in the ICU, hooked up to a BPAP and other various monitors and medical personnel. It was then that I learned that not only had I suffered respiratory arrest but a cardiac arrest as well – in short I “died” on the table. After a little more than a day in the ICU, I was discharged home. Not long afterwards I received a letter from Excel Utilization Review (UR), the UR company that my Adventist Health claims adjuster, who shall remain “nameless to protect the guilty” so I’ll just call her Ms. CA. Apparently she thought that my surgeon’s decision to have me admitted to ICU after such a serious medical event required a review and approval of Excel, you know just in case it was an inappropriate and costly decision to admit a patient who’d suffered a full respiratory and cardiac event to ICU. Yeah, you read that right, Adventist Health, a hospital/healthcare corporation, was unsure that my surgeon had made a medically sound and financially correct decision!

Excel denied my admission to ICU! However, in their defense one of the reasons was the failure of my surgeon to send them “appropriate” information, but as a medical professional myself I was rather incredulous that they (Adventist Health and Excel) even questioned the need to admit a patient to ICU – most surgeons don’t just do this on a whim. But this is Workers’ Compensation after all so logic goes out the window and often doesn’t seem to apply.

Sometime later I received another letter from Excel that approved my ICU stay – whew! The irony was that Excel actually commented that the average ICU stays in a case such as mine was just less than 5 days, while I stayed just over 1 day. So while Ms. CA thought my stay was possibly inappropriate and costing Adventist Health unnecessary money that turned out not to be the case.

In the meantime, Ms. CA refused to return me to “total temporary disability” (TTD) status as order by my surgeon and have taken no action to discover what might have happened to cause this serious medical event.

Stay tunned for more . . . .

Just a little over a year ago tragedy struck San Bernardino (SB) County when two radicalized individuals attacked SB County employees during a training/holiday party. 14 people were killed and 22 more were seriously injured that fateful day on December 2, 2015.

Flash forward a year and the public discovered that many of the 22 seriously injured employees are having to fight tooth and nail to get treatment through our state’s horrible Workers’ Compensation program. You can read about their struggles in the coverage provided in the Pasadena Star News and in the Los Angeles Times. Being a person who, while not a victim of such a horrible attack, has been winding my way through the Workers’ Compensation system for my work-related injury felt compelled to respond. You can read my letters to the editors that were published in the PSN San Bernardino terrorist attack survivors and the LTE SB Attack.

San Bernardino County isn’t the only self-insured employer who seems to be abdicating their responsibility to care for their injured worker and help them return to pre-injury condition, as much and as quickly as possible. This employer isn’t the only one; next up I turn the spotlight on Adventist Health and how they provide compassionate and excellent care to their injured workers – NOT!

Enough is enough

Since April of last year there has been the constant drone from the California Nurses’ Association (CNA) and their supporters of “just let the Huntington Memorial Hospital (HMH) nurses vote”. Elected officials such as Congresswoman Judy Chu, Pasadena City Councilpersons, Gordo and Tornek, former Pasadena City Councilperson Robinson, various “community leaders” and others have picketed the hospital, held rallies, written letters to the editor and what not echoing this simple plea. However, when the vote which was held in April 2015 showed that a majority of HMH nurses voted no to having union representation these same individuals who claimed they were only interested in the HMH nurses getting to vote suddenly had a change of heart and cried foul, demanding that the vote be stricken and a new vote taken even though well over 90% of eligible HMH RNs came out to cast their vote.

As expected both the CNA and HMH leadership filed charges with the National Labor Relations Board (NLRB), each claiming that the other side had made one type of violation or another. The NLRB rendered numerous decisions, some in upholding the CNA claims and dismissing others. In the meantime the campaign to disparage the care at HMH continued unabated. Even after the CNA and HMH agreed to set aside the vote and hold a new election there were those CNA supporters who seemed unable to control themselves and continued their attempts to vilify HMH and its leadership.

One such person is an individual named John Grula, PhD who writes a column for the Pasadena Weekly. He’s most recent diatribe against HMH can be found here – http://www.pasadenaweekly.com/cms/story/detail/outbreak_of_truth/16130/.

He makes many claims in his article, which on their face sound absolutely outrageous. Claims such as CNA-affiliated RNs provide the best patient care in our state. To bolster this claim he brings up the Olympus scope and how the failure to properly clean them lead to bad consequences for many patients. He goes into great detail about these incidents that occurred at HMH, but failed to mention that there were at least two other LA-area hospitals that had similar outbreaks and breeches in reporting such outbreaks. One such hospital was UCLA Ronald Reagan Medical Center, which ironically he cites as having CNA-affiliated RNs that provide the best care in our state.

At the beginning of Grula’s article he cites a June 1, 2016 LA Times article which if you don’t read beyond the first paragraph paints a dim picture about how HMH handled the drug-resistant Pseudomonas aeruginosa. However, if you read the full article, which you can find here — http://www.latimes.com/business/la-fi-huntington-hospital-scopes-20160601-snap-story.html, a slightly different picture emerges. The article lays out the problem was not just at HMH, but at hospitals across our nation, it also lays out the steps HMH took to correct the matter.

His article goes on to mention the firing of two HMH nurses, which the CNA and their supporters claimed was in response to the nurses’ pro-union stance and unionizing activities. He then writes that the NLRB agreement rescinded their termination, removing any mention of termination from their employment record, that they received back pay and that one nurse had returned to HMH. While some of his statement is correct, he fails to mention that while any mention of their termination was removed from their employment files notating instead that they had voluntarily resigned. Grula goes on to claim that one of these nurses chose to return, but my research shows that the nurse he claims returned to work at HMH, hasn’t. The reason for this appears to be related to the NLRB agreement, which bars both nurses from ever working at or having any business with HMH now or in the future. Not to mention that I know that at least one complaint has been filed with the California Board of Registered Nursing (BRN) about the nurses and the possible violation of our nurse practice act. Several weeks ago, I learned that several HMH nurses have admitted to being questioned by the BRN. Now whether this goes anywhere remains to be seen.

In the end, I find it ironic that the CNA and their supporters continue to rant and rave about giving the HMH RNs a voice, but seem to ignore that their “victory” at having the HMH vote overturn effectively gaged the voice of the 539 HMH RNs that voted no to union representation. Throughout this entire contested voting period the CNA and their supporters seem to only advocate for the 445 HMH RNs that voted for union representation and minimize the fact that a majority voted not to unionize.

Where are the CNA and their supporters speaking out in support of these nurses? Nowhere I guess, because it would appear to me that the CNA and many of their supporters appear ethically and morally challenged to acknowledging that these RNs might actually feel that they don’t need a nursing union to speak for them.

You may recall that back in September of last year I blogged about at least one complaint being filed against Nurse Allysha Almada and Vicki Lin with our Board of Nursing (BRN). It’s come to my attention that BRN investigators  have interviewed several Huntington Memorial Hospital (HMH) nurses regarding the Almada/Lin affair.

At this point I have no idea what these nurses told the BRN investigators or what questions that the BRN investigators had for the nurses. However, as I learn more I’ll be sure to share the information on The Nurse Unchained. Of course the BRN investigators may conclude that there wasn’t a violation of our nurse practice act in which case the allegation can be closed with or without merit. However if its decided that the allegation is substantiated then the allegation can be refer to the Attorney General for formal disciplinary action or refer to cite and fine. This is call an accusation and if a nurse has an accusation filed against him/her it will show up on a license search.

You can learn more about the complaint process by pointing your browser here

Also point you browser here for my article on the California BRN WNM California BRN1

Here we go again, at the begin of June, just 4 days shy of the scheduled NLRB hearing regarding Huntington Memorial Hospital (HMH) and the California Nurses Association (CNA); the news broke that HMH and the CNA had come to an agreement. The papers spun it as if it was a victory for the CNA and the two nurses that had been fired, over the “evil” HMH and its management.  HMH reportedly terminated Alysha Almada and Vicki Lin for violating hospital policy, however Almada, Lin, their supporters and the CNA argued that they had instead been fired for their activity in trying to unionize the HMH registered nurses. An attempt that failed with 539 HMH nurses voting NO to 445 HMH nurses voting YES (with 171 additional votes being challenged by one side or the other).

Our local media herald the “rehiring” of Almada and Lin, even going so far as quoting Almada that she had “decided to decline returning to work at HMH because for the past six months I’ve been working at Keck USC, a hospital where RNs enjoy a CNA contract”. However I received an email (which you can find attached at the end of this post) that tells a slightly different tale. Yes, Almada and Lin’s termination was rescinded, but this termination was replaced with voluntary resignations. However what struck me as odd was that part of the agreement assured that neither Almada nor Lin would never be permitted to obtain employment or have any other business relationship with HMH; a caveat that I found very interesting.

Still unresolved through all this is what is happening with the complaint (at least one that I know for a fact was filed, and another that has been filed which I cannot confirm) about Almada and Lin’s action that were filed with the California Board of Nursing (BRN). I’m not sure if the BRN is moving forward with the complaint, but if they do and if the BRN does decide that their action was indeed a violation of our nurse practice act then an accusation will in all likelihood follow. I wonder if that indeed happens will our media report on this or just ignore it? Only time will tell.

Meanwhile, various newpapers, including the Pasadena Star News, Pasadena Weekly and Pasadena Independent spun the agreement as some sort of victory for the HMH nurses, but never once interviewing a single one of the 539 nurses who voted no to CNA representation. Not a single reporter asked them what they thought about their votes being thrown out at the request of, ironically enough, the very nurses union that Almada and Lin argued were all about giving nurses a voice. I guess the only nurses deserving a voice in their opinion are those that favor a nurses’ union and the rest be damned.

As promised below is a copy of the email that nurses forwarded to me, and though I have confirmed that it wasn’t a confidential internal memo, I’ve redacted private and contact information to protect my sources.

eMail HMH v CNA Settlement

Once again, the CWC & Risk Conference organizers, exhibitors and presenters made good on their promise to deliver a conference that was packed and stacked with information. The venue was the St. Regis in Dana Point and the meetings ran pretty much from 8:00 in the morning 17:00 in the evening every day for three days.

I attended as I have for the past several years to educate both my readers and myself on the workers compensation system and to keep abreast on changes that affect the injured worker and the employer. This year’s conference didn’t disappoint.

I arrived too late in the day on Wednesday for the wonderful breakfast, but in time to attend a session that I thought might prove interesting. The session entitled “MSA Cost Mitigation: Strategies to Reduce Future Medical Exposure” was eye opening and helped shed light on how the defense side of Workers Compensation “thinks” when it comes to providing treatment to and for the injured worker.

MSA or Medicare Set Asides need to be calculated in many Workers’ Compensation cases, especially in those cases where the injured worker is already a Medicare beneficiary or will become Medicare beneficiaries within 30 months or where the injured worker is eligible or receiving Social Security Disability Insurance benefits (SSDI). Since this can have an impact on yours truly, needless to say I listened with rapt interest.

The speaker provided us with many examples of how an employer could control medical costs, however as a nurse I thought that some of these cost-saving measures came at the expense of the injured worker. The speaker gave the example of Gabapentin versus Neurontin. Gabapentin as with generics cost much less than the brand name medication Neurontin. She explained that by switching to the generic the employer could save as much as 2,124.30 a year on a claim. She went on to explain that even more money can be saved depending on the number of pills ordered based on milligrams; for example if the physician ordered one 800 mg pill a day an even greater cost saving can be realized if the following combination was ordered two 300mg pills (at a cost of .03 cents/pill) and two 100mg pills (at a cost of .02 cents/pill). The cost then goes from $85.80 to $3.00 a month. Of course this means that the injured worker must take a total of four pills a day instead of one pill a day, but hey what a cost savings!

The speaker explained that to make such adjustments the client must be a willing participant and that other conditions such as generic must already be available on the marketplace and that the client must already be using the generic. She suggested that if the employer took the long view and was in a position to anticipate when the generic of a specific medication would become available on the marketplace then it might serve the employer well to delay the MSA until the generic was available so the cost of the generic could be included instead of the brand name, once again providing a cost saving to the employer.

And while I am very much in favor of saving, I think it’s critical that the injured worker be truly part of the decision making process. Though the speaker made a point of using the term willing participant to refer to the injured worker I think there’s a fine line between willing and coerced.

Our local paper recently published an article about two Huntington Memorial Hospitals with the claim made by the nurses that they were fired due to their union activity.  However there’s more to the story and below you’ll find both the link to the above mentioned article and my letter to the editor — that the Star News chose not to publish.  I think they were afraid to encourage their readers to think beyond the pablum the union was spoon feeding to both the paper and its readers.

Huntington Memorial terminated 2 nurses; both claim retaliation for efforts to unionize

Dear Editor:

Nurses Almada and Lin with the help of the California Nurses Association (CNA) held a rally to demand that Huntington reinstates the two nurses. The claim is that these two nurses were unfairly terminated due to their support of the recent failed unionization effort at Huntington Memorial. If what they claim is factual, then shame on Huntington Memorial.

However, as a nurse with more than 40 years of experience at all levels of the nursing ladder I’m somewhat hesitant to take their tale at blind faith. Why? Because the hospital is bound by confidentiality in all personnel matters and Almada, Lin, and the CNA know that and are counting on Huntington to adhere to this code. Meanwhile, they can sling all the mud that they want, which they’ve been doing over a year now with support from much of the local media and many local officials who enjoy union support.

I’d prefer to wait and see, because something tells me that there’s more to the tale of the firing of these two nurses than just their involvement in the failed unionization attempt. My nursing instinct tells me that these two nurses may have failed to adhere to our nurse practice act and if this were the case then firing them would’ve been the appropriate action. I also think it is interesting that they’ve made a big deal about going to the NLRB, but said nothing about filing a complaint with our state’s labor board. Not to mention it’d be an act of ultimate stupidity on the part of Huntington to fire any nurse at this time except for cause.

Once a year more than 2,000 people gather in Las Vegas to attend a five-day conference on all things pain related. The attendees aren’t just researchers, but all types of healthcare providers and patients as well. I started attending PainWeek nearly three years ago and each year I return with even greater knowledge about pain and more specifically the latest in treatment for my condition — Complex Regional Pain Syndrome; a condition I developed as a direct result of my work related injury.

This year’s conference had several session regarding workers’ compensation and I had the opportunity to attend Dr. Matthew P. Foster’s session on “Pain Management in Workers’ Compensation: Overview of Spend, Utilization, and Treatment Guidelines”. The room filled up quickly, leaving only a few empty seats.

Dr. Foster’s presentation moved quickly explaining how workers’ compensation treatment and drug prescription moved from whatever, without questions, that the doctor ordered for the injured worker to more and more states adopting guidelines that were either created by the state or that followed the Office of Disability Guidelines (ODG) or that followed the recommendations of the American College of Occupational & Environmental Medicine (ACOEM) or that followed some combination.

His presentation showed that by using treatment guidelines, most states had shown some “control” over the rising costs of workers’ compensation, with the exception of State of New York (which has created its own treatment guidelines). One area where treatment guidelines seem to have the greatest impact was in the approval of opioid treatment for injured workers suffering extreme and/or chronic pain. Many insurance companies and their adjusters have used these guidelines, not such as a guide but much more like something which to adhere to very strictly without wiggle room. Nowhere is this more apparent than with prescription opioids.

It was during the question and answer section of Foster’s presentation that members of the audience brought up very similar tales of adjusters using guidelines to basically “cut off” the injured worker from any opioid medication beyond what the “guidelines” suggest. A common thread was the following: the earliest the insurance company will allow a patient refill of their opioid prescription is 28 days (2 days before the patient’s current script ends), when the patient turns in a new script at the 28 days mark some insurance companies then ask for 7 to 10 days to authorize the new opioid script thus leaving the patient without opioid medication to cover for that time period placing the patient at risk for withdrawal, not to mention the emotional and psychological impact the fight every month to fill their physician order medication has on the injured worker. Meanwhile in California a great many of the utilization review physicians are from ER specialty a discipline that doesn’t prepare the physician to take care of patient for the long term, an observation that I shared with the audience and with which the audience agreed.

So in short when it comes to opioid prescriptions the injured worker is basically made powerless by the very program that’s been put in place to “help the injured worker return to pre-injury condition as quickly as possible”.

Thanks to several high profile news articles and news reports a heightened awareness of opioid pill mills and the doctors that run them came into the awareness of not only the American people, but various government agencies, as well. This was not such a bad thing, but what was never addressed by the news articles (many covered in the Los Angeles Times) were the thousands of patients living with chronic pain that were finding benefit from opioids and the conscientious doctors that made a point to monitor their patients for compliance.

The constant focus on those who die from opioid abuse and the doctors that prescribe opioids willy-nilly overlooks the reality that many more people have benefited from opioid use and do so without abusing the medication. The 2012 LA Times series on opioid abuse and deaths has been referenced in nearly all opioid cautionary articles since the series first ran with the factoid that between 2006 and 2011 there were 3,733 opioid-related deaths in four Southern California counties (Los Angeles, Orange, San Diego and Ventura). Though 3,733 is a staggering number of opioid-related deaths, the LA Times reporter failed to provide perspective; such as, during this same period of time there was a total population of 16.9 million people (as of June 2011) in the abovementioned counties and these opioid-related deaths though tragic represents .0002% of the population – my question then how does this make a raging epidemic?

Also missing in many of the reports of opioid abuse is how many individuals were not only addicted to opioids but to other drugs (both legal and illicit), and alcohol. Little effort was done on the part of the experts and reporters alike to deduce which came first the opioid abuse or the alcohol/illicit drug use. Actually in the LA Times series, it was noted that in many of the deaths that were reported as being opioid-related could only be assumed, since at the time of death the death wasn’t identified as an opioid-related death.

While the LA Times did a relatively good job at highlighting deaths related to opioid-abuse they did a disservice by not providing context and by failing to present stories from those living with chronic pain for which opioid use is the only treatment. Instead as a response to the LA Times and other similar articles various agencies and regulatory bodies began to discuss ways to “curb” the opioid epidemic. Meanwhile, few if anyone was talking about what could be done to provide support to those living with chronic pain for which opioid treatment was the only option or one very important part of their therapy to alleviate the constant, chronic pain– because that would be too easy! While the LA Times targeted California for its pill mill and opioid-related deaths (remember 3,733 people died), they failed to mention that California had the lowest person to opioid rate of all 50 states. They failed to address how insurance, in particular Workers’ Compensation, seemed reticent to provide alternative treatment for people living with chronic pain. For example, Workers’ Compensation puts a cap on the number of physical therapy (PT) sessions an injured worker can have, in total, over the course of an injury. This doesn’t mean that a Workers’ Compensation adjuster can’t approve more (PT), but far too many adhere to the strict guideline; even if PT is the recommended course of treatment for recovery from a particular procedure, so all too often doctors have to rely on opioid treatment in lieu of PT.

While it may seem as though states regulatory agencies have done little to curb opioid abuse a map/document produced by Progressive Medical outlined with some thoroughness state opioid rules by restriction, and though this document was published in 2013 it provides a good snapshot of these restrictions by state and can be found here – OpioidRulesByRestriction + MAP_10-15-13_FINAL.

So with so many people and agencies focused on the “problem of opioid-abuse” no one seems willing to advocate and address the needs of people living with chronic pain for which opioid treatment is the only option. There’ve been a few groups that have spoken out, but their voices are often muted by the screams of those who seem intent of removing opioids completely from all formularies. Prescription Drug Monitoring Programs (PDMP) such as California’s Controlled Substance Utilization Review and Evaluation System (CURES) programs have shown little effectiveness. Meanwhile, CURES has a very low utilization by California physicians and pharmacists. Meanwhile few states, including California’s CURES updates in real-time. Oklahoma is one of the few states whose program updates with very little lag-time which allows both prescribing physicians and pharmacists to access the Oklahoma PDMP in real time which helps weed out pill shoppers and helps in the identification of possible pill mills.

Draconian measures will not solve the challenge of opioid-related deaths or abuse or those running pill mills. What’s needed is a balance and sane approach. Doctors need to be well educated on when opioid use is optimum, how to detect possible doctor shopping, non-compliance and so forth. In turn patients and their families need to be educated on appropriate opioid use and provided tools to be both compliant with treatment protocol and to be aware of possible signs of opioid dependency. For example patients who are in extreme pain may not be cognizant that they just took their Vicodin because when a patient is in a state of extreme pain they experience time differently. I should know I had to endure an Ilizarov external fixator for a time and if not for a note that I kept at my bedside where I would document each time I took the Vicodin that had been prescribed to me there would’ve been times when I could’ve sworn that two hours had already passed since my last dose. I can’t recall one occasion where physician, nurse practitioner or nurse ever recommended a method to track when medication, especially opioids, that had been taken.

On the upside conferences such as PainWeek offer caregivers, practitioners and patients alike an opportunity to learn about the various manifestations of pain and the different modalities to treat pain. I’ve truly enjoyed attending PainWeek these past two years and I am looking forward to more networking this year.