1	The Surgical Cases: Psychological Complications & Solutions
2	Work Related Injuries in Georgia
3	Our Agenda: How to Maximize Outcome Common Pre-Surgical Concerns Common Post-Surgical Complications Factors Affecting Patient’s Perception of Disability How to Order and Utilize a Psychological Examination to effectively deal with a, b, and c
4	Psychological Statistical Review Two thirds of back injured patients may have had pre-existing psychological disorder As much as 51% of back injuries cases had pre-existing personality disorder Georgia cases often have 8^th grade education, 4^th grade reading and sub-average IQ
5	The Synonym List Used to Avoid “Psychological” Functional Overlay Conscious Embellishment In excess of objective findings Non-physiologic Indicators Symptom Amplification
6	Work Related Knee Injury
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10	Why Psychological Exams are Postponed False Conception: Let’s Exclude All Possible Physical Causes first and “see where it goes.” Fear of Offending The Patient or Surgeon Lack of Clinical Sophistication on the Surgeon’s, Nurse’s, Adjustor’s, or Attorney’s Part Mistake: Waiting until the last moment to obtain psychological data. This makes the request seem like a blockade, rather than a necessary gathering of information as part of the surgical decision. Solution: Build Your Psychological Database Even While Physical Tests are Being Obtained.
11	Questions to Ask the Physician Reasonably full description (not just the name) of proposed procedure Summary of objective data (x-rays, etc) which indicate well-defined need for surgery Surgeon’s perception of patient’s past compliance with conservative management, such as p.t. and medication Predicted likelihood (%) of a successful surgical outcome Surgeon’s definition of a successful outcome (vs the patient’s expectations)
12	The Game Plan Request that your nurse case manager meet with the patient, spouse or immediate family, prior to final decision to proceed with surgery Ask the surgeon: How long should the hospital stay be? What will be the criteria for discharge and medication management, and when should you expect physical therapy to begin? What is the normal length of time required for most patients to reach MMI with this procedure? What are the likely residual physical limitations based upon the surgeon’s experience?
13	Pre-Surgical Evaluation Patient referred prior to diskectomy Lumbar bulge/nerve involvement is well documented by diagnostic studies Physician was uncomfortable with patient’s presentation Adjustor uncomfortable with lack of patient’s concern for proposed surgery.
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17	The Patient: Psychological Red Flags
18	Psychological Red Flags for the Surgeon Patient is already using medication beyond that recommended, calls between appointments for refills, sees more than one physician or uses mx pharmacies Patient asks questions that indicate lack of understanding of proposed procedure Patient asks NO questions about proposed procedure Spouse is handling all phone calls and filtering all information Patient has not been fully compliant with p.t., injections or other conservative recommendations Patient’s symptoms are inconsistent from one visit, or from one physician, to the next Surgical date is postponed more than once due to questionable conflicts Unspoken fears regarding surgery The patient is complaining of more pain and urgency than may truly exist
19	Psychological Red Flags for Adjustors and Case Managers The surgery is coming very late in the injury process after repeated and unsuccessful conservative care The diagnostic findings are underwhelming, but the surgeon still wants to do the procedure A second opinion is resisted by patient, doctor or attorney The patient does not have a good support system for post-operative home recovery The patient has not been compliant with care-to-date The surgery seems to be recommended because the patient fails to report relief from conservative management; not because the objective data indicate a pressing need (such as cord impingement)
20	Post Surgical Chronic Pain 38 y.o. woman, tripped over drawer Laminectomy & Diskectomy have resulted in chronic pain Alcoholic father died, mother moved to Florida, ex-husband died, lover has lymphoma – all same year Cause of her pain? Workers’ compensation denied the claim
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23	Insurer/Employer Error Patient suffers from recurrent major depressive disorder Case has merit Some complaints exacerbated by injury Patient sought only 4 visits Patient could have reduced pain medication if prescribed an antidepressant Ultimately resolution will be postponed by denial of care
24	Pre-existing Disorders Sometimes, an injury is severe enough that even significant pre-existing disorders must be addressed as part of a claim. Massive trauma to a limb resulting in treatment-resistant RSD or other permanent limitations Multiple trauma from a high fall resulting in fractures, surgery and protracted recovery Sexual or physical assault with resultant PTSD. Narcotic addiction when prescribed (iatrogenic) by the treating physician, even if the patient has a drug and alcohol history
25	Overtly vs. Covertly Psychological Overtly Psychological Claims of Depression or Anxiety Claims of Posttraumatic Stress Disorder Claims of Inability to live with Excessive Pain Covertly Psychological Anger & Resentment Suspicion & Distrust Entitlement & Deservedness Denial of Addiction
26	Pain Management Programs: the psychological factors Who determines candidacy? How was the need for referral determined? How are goals determined? How is progress measured? What is the structure/length of care? What is the contingency plan if the program is not successful? Is the need for pain medication increasing, rather than decreasing, over time? Does the amount of narcotics increase over time, while antidepressants are under-utilized?
27	Depression, Sleep, Narcotics & Pain Centers - the Psychological Realities Is the patient depressed as a result of pain? Is the patient unable to sleep because of the impact of narcotics on sleep architecture? What are the plans for the future use of narcotics with this patient? If injections fail, will the patient be able to cope with pain if narcotics are halted?
28	Work-Related Hoarseness Patient is police dispatcher Dispatches officer into line of fire Patient feels guilty Patient becomes hoarse Physical findings are negative Referral Question: “Can this be psychological?”
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32	Ten Critical Data You Must Have The Patient’s Developmental History The Patient’s Educational History The Patient’s Criminal History The Patient’s Medical History (addiction?) The Patient’s Work History The Patient’s Recounting of the Accident The Patient’s Understanding of the Injury The Patient’s Perception of Care The Patient’s Needs and Goals The Patient’s Diagnostic Findings
33	Psychological Reports Should Contain Brief/Relevant Developmental history Relevant Medical/ Injury History Educational & Employment History Patient’s recounting of injury and care Clinical Observations Appropriate Diagnostic Testing Clear & Useful Recommendations
34	Minor Skin Burn Patient works brief labor position Sustains minor dominant hand burn Abuses narcotics, now discontinued Continues to abuse alcohol Wife leaves Hand falls into disuse, RSD develops Case about to settle; patient’s hand becomes useless, requests amputation
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37	Psychological Findings Factitious Disorder suspected Patient unlikely to participate in own rehabilitation Discussion with surgeon who feels amputation is now unavoidable Decision to treat as amputation, discharge with PPD rating following surgery
38	Laminectomy 38 year old male Father died in airplane crash Lifting 150 lb machinery Chose surgical option
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41	Psychological Findings Patient has injury and non-injury related triggers for major depressive disorder which complicates surgical recovery Financial consequences & separation Niece, her children, her boyfriend move in Harassment by ex-boyfriend Niece, daughter and boyfriend killed Insurer would like to deny all psych as pre-existing
42	Mandatory Psychological Exam Assault Cases Traumatic Loss Cases Unresolving Cases Cases of Focused Concern: Complaints exceed findings Patient briefly employed Patient resists re-employment
43	Lumbar Injury – Post Surgical Injury: 40 yo 2x divorced female, 12 months post fall & lumbar injury, working for warehouse for 4 months. Has had 2 surgeries. Patient continues to complain of pain, takes excessive medication. Case Management: Trying to see if employer has light duty. Orthopedic Decision: Patient is at MMI; physician feels patient must be depressed since she declines a return to work. Patient’s Attorney: Depression resulted from fall; needs care
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46	Psychological Findings Psychological Findings: Patient suffers from pre-existing borderline personality disorder. Abused by disabled parents, sexually assaulted by two sibs, physically abused by first husband and in-laws, brother and stepfather in prison for murder, patient has record as habitual offender, past drug abuse history. Psychological Conclusions: Recurrent depression due to developmental crises, refer to CAMHC, not disabled from work within limitations, prefers patient role, will not seek to settle.
47	"OnLine Referral System (via..." OnLine Referral System (via the Internet) Psychological Letters (Newsletters) Case Management Updates via E-mail Question of the Week Factoids Definitions of Mental Disorders and Treatment
48	Conclusion
49	Work-Related Arm Injury Working in housekeeping Pulling out trundle bed Has had 11 stellate ganglion blocks Has had sympathectomy Has had SCS implant Seeking additional surgery Insurer wants to know her “candidacy for additional surgery”
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52	Psychodiagnostic Findings 10^th grade educated w/deceased alchoholic father; mother died in DT’s after beaten by 7^th husband Patient sexually assaulted beginning in childhood by mother’s boyfriends then locked in closet by grandmother so assaults could not be reported Sibs and own children are addicts, youngest daughter a stripper, raped by a husband’s friend, then committed Raped again when seeking shelter in trailer park Averaging 8 new residences per year. Married seven times Borderline Personality Disorder, Mood Disorder, Polysubstance Abuse Disorder as well as Factitious Disorder Surgery was contraindicated Patient settled but there was concern regarding her ability to manage own finances.
53	Work-related Lumbar Injury Venezuelan female injured working in housekeeping Lumbar herniation lifting trash bag Conservative measures not successful Surgery scheduled Employer asks for routine psychological examination regarding suitability for surgery
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56	Psychodiagnostic Findings Passive dependent personality Prior office worker and in sales Isolated during the days; no English, battling teenage daughter’s entry into American culture Father died due to surgical complications Patient was told by surgeon that she had: 5% chance of infection or symptoms not improving 95% probability that all symptoms would resolve Creating nerve damage by delaying surgery Psychologically patient is a poor surgical risk Education of patient may improve prognosis