A guest post by the excellent Dr Kar Loong Ng of Next Generation Occupational Medicine – NGOM.
Time. Timing. Such a critical aspect of Medicine. When a patient is in VF (Ventricular Fibrillation) the medical team has seconds, tens of seconds to act before the probability of successful resuscitation decreases exponentially. Act too fast (not yelling ‘CLEAR’) whilst activating the defibrillator and they risk hurting a team member and losing further precious seconds whilst the machine recharges. Act too slow and the patient is lost forever.
The same principles apply for non-emergency musculoskeletal workplace injuries. More often than not, I encounter patients, employers and insurers who request for MRIs at early stages of injury when there is no medical indication. The fact of the matter is, there is very little correlation between most MRI findings and the patient’s current injury or problem. Kind of like seeing all the imperfections on footy player’s faces on a 4K TV during a game. Additionally there are quite a large number of studies that show that early spinal MRIs that are not medically indicated often result in poorer outcomes and disability. I once saw a worker who was in such severe pain due to his belief that his ‘discs are squashed, bulged and spinal cord and nerves crushed’. When viewed I his MRI scans and told him that there is mild bulging of his lower 2 lumbar discs , his immediate response was “That’s where my pain is !! Between my shoulder blades……..”
Another example is that of shoulder impingement syndrome. A subacromial injection early on the injury is not going to be of benefit if the patient is not aware of how to perform rotator cuff exercises. An injection too late will also have less chance of success.
It is all about timing. Right, Roger Federer?
I previously wrote about Specialised Early Intervention and Second Opinion Medicine. With both services, we have been able to successfully rehabilitate a good proportion of complex worker injuries to normal work, alternative work, new employment or community restoration. Unfortunately some patients do not do so well. Being a sub-specialist practice, all our patients are referred from GPs. Despite extensive communication to the GP community, employers, insurers and rehabilitation providers emphasising the importance of early referrals, our earliest referral over the past few years has been 7 weeks post injury. This was an outlier, with the average referral being 6 to 9 months old. Well…….it beats my record a few years back when I saw a 50 year old man (with a six-pack) who had been on benefits since 19 and could not remember which leg his sciatica was on………..
Successful Early Intervention requires implementation at 2 to 3 weeks post injury. Some people refer to it as ‘The Golden Month’. For complex worker injuries, there is now good evidence that screening and intervention at day 1 of injury result in a significant reduction in disability and cost.
We are now in the process of implementing this with the introduction of services to GPs. The aim is to provide patients, workers and employers with a personally tailored comprehensive suite of medical and allied health care, as well as quick but well-timed access to medical sub-specialists.
I feel like I have been playing the game of RISK over the past few years. Disability is the enemy. I hope this strategy contains it.
Thanks Kar – it’s inspiring to see the passion you have for returning injured workers to work! Getting you better is what we’re about at Partridge Street General Practice and so we’ll be working together with NGOM whenever we see injured workers.