Workplace Health Fall 2023

Exciting Advancements in Pain Medicine

Ankur Patel, DO, RPH

There is a long gap between clinical trials and when new products become available to clinicians for actual treatment, despite constant ongoing research in the medical field. This entire process can take ten to fifteen years in the research and development phase alone. So, when new technologies and treatments are introduced in the marketplace, doctors become a bit like the old saying, “kids in a candy store.”

As we commonly see in our workers’ compensation arena, patients’ injuries are often an aggravation of a preexisting condition. Those common conditions include degenerative disc disease and spinal stenosis. Until now, pain management physicians had a limited amount of resources to treat these types of ailments. We have always maintained a culture where minimal to no opioid use was the accepted standard, but we have struggled to offer new treatments to get patients back to a pre-injury level of pain control. Specifically, many claimants have chronic pain prior to their injury, yet no clearly defined path or treatment outside of major surgery or the aforementioned injections and neuromodulation.

That being said, it’s an exciting time to be a pain management specialist. While we continue to have our common and most consistent treatments such as epidurals, facet blocks, large joint injections, and, of course, spinal cord stimulation, here are two (2) new tools being used more frequently to get patients back to a baseline level of pain control. here are two (2) new tools being used more frequently to get patients back to a baseline level of pain control.

Via Disc NP is a human nucleus pulposus supplement. It is injected directly into the vertebral disc via a 20G needle. Intended to help offset mechanical loading of the disc, it is a non-surgical intervention that supplements age-related wear and tear of the disc secondary to dehydration and degeneration. Candidates for this procedure typically have no major stenosis, disc herniation, or outward surgical pathology. Disc degeneration is a common MRI finding in these patients.

Minimally Invasive Lumbar Decompression (MILD) is a newer procedure used to treat lumbar spinal stenosis and can be helpful as an alternative to major spine surgery. Years of wear and tear on the body/spine lead to ligament hypertrophy, bulging discs, and excess bone growth causing mild to moderate spinal stenosis. These patients typically present with pain and numbness/tingling in the lower back and down the legs. Their symptoms are made worse when standing or walking and relieved when sitting or leaning forward. This procedure is done via a small incision whereby a specialized tool is inserted on the superficial surface of the spine and excess bone and/or ligament is removed. Typically, the procedure takes an hour and is done on an outpatient basis with minimal sedation and a recovery time of one day.

Again, while the injury may not be a direct cause of these conditions, the aggravation can be treated with minimal outpatient procedures such as these to help get patients back to baseline. Of course, we continue to provide multi-modal treatment options. An appropriate course of physical therapy, nonopioid-based medications, and additional hot/cold therapies continue to be mainstays of treatment combined with these new options.

Ankur Patel, D.O., RPH, is a board-certified anesthesiologist, pharmacist, and fellowship-trained interventional pain management physician at his new practice, Southern Pain and Spine in Gainesville, GA. He is dedicated to advancing patient care to the highest levels via a conservative approach to medications while using his interventional pain management training under the tutelage of Gabor Racz, M.D., and Miles Day, M.D., at the prestigious pain fellowship on the campus of Texas Tech University Health Sciences Center in Lubbock, Texas. Southern Spine and Pain has additional offices in Athens, Jasper, and Newnan, Georgia.

2023 Upcoming Educational Events: Workplace Health Magazine gets around!

Disclosure: Event dates could be postponed, cancelled, or virtual. Please use the following as a guide. If you would like your event added to the Workplace Health magazine calendar of events, please contact Michelle Wilds at michellewilds@selectonenetwork. com. Workplace Health magazine would love to come and cover your event.

August

7-9 – Alabama Self-Insurers Association

Summer Conference – Sandestin, Florida

20-23 – Workers’ Compensation Institute – Orlando, Florida

26 – A Night with the Jaguars – SHRM Jacksonville Member Appreciation Event

27-30 – Georgia State Board of Workers’ Compensation Annual Conference –Atlanta, Georgia

September

6-8 – Georgia Safety Health and Environmental Annual Conference –Savannah, Georgia

13 – Swift Currie Symposium - Atlanta, Georgia

14 – Strategery, SHRM Jax – Jacksonville, Florida

14-15 – Alabama Department of Labor

Workers’ Compensation Conference –Huntsville, Alabama

20-22 – National Workers’ Compensation and Disability Conference – Las Vegas, Nevada

26 – Fall SHRM Jax Happy Hour and Networking – The Igloo, Jacksonville, Florida

27 – Workers’ Compensation SeminarMacon, Georgia

October

4-6 – International Workers’ Compensation Foundation North Carolina – Raleigh, North Carolina

11-13 – SHRM Georgia State Council Annual Conference – Lake Lanier Lodge, Georgia

12-13 – Alabama Department of Labor

Workers’ Compensation Conference –Birmingham, Alabama

November

1 – Georgia Workers’ Compensation Association Fall Conference

2-3 – Alabama Organization – Birmingham, Alabama

5-7 – South Carolina Workers’ Compensation WCEA – Myrtle Beach, South Carolina

13-17 – Southern Association of Workers’ Compensation All Conference Committee – San Antonio, Texas

May 2024

5-8 – RiskWorld 2024 – San Diego, California

A Message from the Publisher Leveraging Industry Trust

Trust is the invaluable currency that underpins successful relationships in both personal and professional spheres. In the dynamic and competitive landscape of the business world, trust holds an even more profound significance. It is the bedrock upon which companies build strong partnerships, cultivate customer loyalty, and foster a positive work culture. Leveraging trust is not merely a feel-good concept, but it is a strategic imperative that can fuel growth, drive innovation, and sustain long-term success.

One of the most vital aspects of leveraging trust is establishing solid relationships. People are more likely to engage with those they trust, making it easier to acquire new clients and retain existing ones. Trust is built through consistent delivery of quality products and services, transparent communication, and ethical business practices.

In the Workers’ Compensation industry, there is a whole host of professionals who have spent their careers establishing trusting relationships and have an extensive wealth of knowledge. However, such professionals are retiring and taking their years of experience with them.

Because of this, we must utilize retired industry professionals and their unique perspective that has been shaped by years of hands-on experience and witnessing the evolution of our industry. Their expertise spans not only the successes but also the challenges and failures, providing a well-rounded understanding of the intricacies of the workers’ compensation landscape. This accumulated wisdom can help companies avoid common pitfalls and make informed decisions, thereby saving time and resources in the process.

Workplace Health is proud to announce a platform for these individuals to share their many years of leveraging trust through their experiences and giving back to our workers’ compensation community. We are creating a proactive comprehensive training program that will help prevent costly repercussions for employers in the future through:

• Recommending the best Workers’ Compensation providers and vendors

• Teaching best practices to overcome communication barriers

• How to best handle complex claims with better outcomes

• Providing excellent advice on handling complex claims

• Helping young industry professionals create detailed risk and vulnerability assessments

• Giving proven strategies to help manage risk

No matter what, our goal is to get people to talk and share. The more we do so, the better our industry will be.

Kelly Bentley, Director

of Claims at CompTrust AGC, sums it up best:

Communication is paramount to the claims handling process. Effective and clear communication should be a priority at the beginning of a claim as this is a key part of quality claims handling. It assists in developing clear expectations on both sides of the claim and keeps all parties involved in the process. Injured employees often get “lost” in the work comp world so making yourself available to discuss concerns and questions for them often helps mitigate costs and potential litigation issues in a claim.

Creating this Workplace Health platform will drive better outcomes for all the stakeholders in the Workers’ Compensation system.

Best Regards,

Garlana Mathews – President and CEO /Publisher Workplace Health Magazine

Garlana H. Mathews

Important Florida Legislative Change

G. Jeffrey Vernis

The Florida legislature passed sweeping tort reform legislation on March 23, 2023, and was signed by the Governor at 9:30 the next morning. The new legislation has prompted Plaintiff’s attorneys to file tens of thousands of lawsuits in anticipation of the enactment of these new laws which reduce the statute of limitations for negligence claims, give insurers a ninety-day grace period for bad faith claims, change comparative fault to contributory negligence, and many other procedural changes to “even the playing field.”

Attorney’s fees: Florida Statute § 57.104 was amended to limit the amount of attorney’s fees to the reasonable lodestar fee, but also included that only in rare and exceptional circumstances can a court award a multiplier to the fees.

Statute of Limitations for Negligence: The Legislature reduced the statute of limitations for claims based on negligence from four years to two years.

Service members: Florida has now codified the Servicemembers Civil Relief Act, 50 U.S.C. §§ 501 into Florida law. It provided relief from civil litigation to service members on active duty, as was set for under Federal law.

Bad Faith: In a broad and significant way, the Legislature addressed numerous issues in bad faith law in Florida. We will be providing a more detailed summary of the new laws and protections in another article. However, it is important to note some of the changes. No bad faith claim, either statutory or common law, can be brought if the insurer tenders their policy limits or the amount demanded by the claimant within ninety days after receiving actual notice of a claim “which is accompanied by sufficient evidence to support the amount of the claim.”

The new law also states that “mere negligence alone is insufficient” to constitute an insurer’s bad faith. But in addition, the new law sets a duty on the insured and their counsel to act in good faith and allows for the admission of the actions of the insured/claimant and their counsel in any bad faith action. For multi-claimants competing for a single occurrence and limited policy limits, the law now allows the filing of an interpleader or agreeing to binding arbitration and provides immunity beyond policy limits to the insurer if they avail themselves of these new procedures.

Medical Bills/Letter of Protection: The new law includes specific language on letters of protection and limits the amounts that may be charged by the provider and what may be admitted into evidence and what may be recovered. The evidence offered may only be the amount that has been paid, regardless of the source of payment.

If the medical bills have not been paid by any source and the person does not have health insurance coverage or has Medicare or Medicaid, the provider may only charge 120% of the Medicare reimbursement amounts. If the Claimant has health insurance, they may only charge the health insurer’s reimbursement rate. The law also provides limits and conditions on letters of protection requiring disclosure and limits on the amounts charged by the provider.

Further, the law sets forth what damages are recoverable for medical treatment, limiting the amounts paid by the claimant or the health insurance carrier. It is also important to note that the law also only allows for recovery for future medical treatment that the Claimant “will receive in the future” as opposed to the previous standard of “reasonably certain to incur” in the future.

Premises Liability-Negligent Security: Changing Florida law, the new law allows the jury to “consider the fault of all persons who contributed to the injury.” Previously, Florida law precluded a jury from apportioning fault to the active tortfeasor/assailant, however, the new law requires the jury to consider the fault or actions of the intentional actor/assailant, thereby reducing the fault on the potentially negligent premises owner.

Comparative Fault: In a substantial departure from existing Florida law, the new law moves Florida closer to a contributory negligence state. Under the new law, in any negligence action, if a Claimant is found to be greater than fifty percent (50%) at fault for their injury or harm, they may not recover any damages.

This new law became effective at 9:30 a.m. on March 24, 2023, and applies to all cases filed after the statute’s effective date.

G. Jeffrey Vernis is a Florida Bar Board Certified civil trial lawyer and a managing partner of Vernis & Bowling, handling large exposure and complex personal injury and commercial and insurance litigation cases. He also serves as President of Jeff Industries, a non-profit providing innovative and unique services to those suffering with mentally illness. He also holds a sixthdegree black belt in the Japanese martial art of Aikido and has been awarded a teaching certification (Shidoin) from the World Aikido Headquarters in Japan.

Workplace Health Magazine gets around the WC Community!

Alabama DOL with Steve and Matt

Enjoying the boat ride

GWCA team with Linda Lee and Terry Cruthis

Celebrating with the State Board of WC on their new location in Savannah

Great Panel during the WPH Symposium - Leading the way is Dustin Thompson Attorney

Happy Hour at GA PRIMA conference

Happy Hour in Perdido

Panel discussion with Teri Zarillo, Mark Kamaleson MD and Johnathan Christy MD

Sherri Forbes and Angie Arrowood

MIJS Adjuster Seminar with panelist Stephanie Martin MD, Sharee Tumbling Attorney, and Shane Mangrum MD

RIMS Corvel party at Mercedez Benz Stadium

WPH Symposium with Eddie Kinnard and Kelly Bentley

A Primer on Meniscus Tears

Greg Lee, MD

There are two types of shock absorbers within the knee: the articular cartilage and the meniscus (two menisci per knee). The articular cartilage is the thin layer of shock absorbing material that coats the weight bearing surfaces of a joint and protects the underlying bone. The meniscus is a shock absorbing structure within the knee that shields the cartilage of the joint from excess pressure. The meniscus can be thought of as a ring-shaped, rubbery gasket that is attached to the upper surface of the tibia and absorbs the pressure of the body passing down through the femur. The medial meniscus is located on the inner side of the knee, while the lateral meniscus is located on the outer side.

This shock absorbing function of the meniscus is critical in preventing mechanical trauma to the cartilage, thus protecting a joint from developing arthritis. When meniscal function is lost, the weight bearing pressures applied to the cartilage of the knee increase dramatically and the rate at which the cartilage deteriorates accelerates. Arthritis within the knee ensues after meniscal loss. There are two general categories of meniscus tears: traumatic and degenerative.

Traumatic tears typically result from an injury with the most common mechanism being a twisting or deep knee flexion event while the patient is bearing weight. The damage to the meniscus occurs when the meniscus structure is forcibly entrapped between the firm surfaces of the femur and tibia to the point of mechanical disruption of the meniscal tissue. This event typically results in a fragment of meniscus tissue being made unstable and partially detached from the main body of the meniscus. This fragment is then free to continue to cause mechanical irritation within the joint by repetitively catching between the two surfaces of the joint. The meniscus has very limited blood supply and, therefore, has minimal capacity to heal itself. Typical symptoms include pain on either the medial or lateral side of the knee, pain with weight bearing, pain that awakens the patient from sleep, pain with twisting or squatting upon the knee and mechanical events such as random onset knee buckling or locking sensations.

Surgery is almost always required for traumatic meniscal tears due to the limited capacity of the meniscus to heal itself. Surgery involves either resection of the unstable meniscus fragment (meniscectomy) or surgical repair of the damaged fragment back to the main body of the meniscus. The determination as to which surgical approach is indicated depends on factors such as patient age and the location and pattern of the tear. Repair is only likely to be successful if the meniscus tear is in the limited region of the meniscus in which there is blood supply. Expected time for full recovery after a meniscectomy ranges from 2-4 months. It is important to understand, however, that loss of meniscus function can lead to the development of arthritis in the knee in the years that follow the injury. Future treatment for that arthritis might be required. Expected time for full recovery after a more complex meniscal repair procedure is 8-9 months, as prolonged precautions and activity restrictions are required to allow the limited blood supply of the repaired tissue to fully heal. An MRI is critical for determining what type of treatment is indicated for a meniscus tear.

Normal Medial Meniscus in a Right Knee

Degenerative meniscus tears occur without a defined moment of injury and typically occur in patients who have reached the age of 40-50 years. In the scenario of a degenerative meniscus tear, it is helpful to think of the meniscus as a tire on a car. Every mile a person goes, the meniscus structures within that person’s knees

Anatomy of the Meniscus; View from the front of a Right Knee.

(*on Meniscus, F on Femur, T on Tibia)

feel pressure and strain. Like the tire on a car, the meniscus cushion can eventually mechanically weaken and have a “blow out”. Symptoms can be similar to those described for a traumatic tear. Often, with degenerative meniscus tears, x-rays and MRI scans show some degree of arthritis present within the knee. It should be noted, however, that a traumatic meniscus tear can occur in a knee with a degree of arthritic change, with the knee arthritis having been asymptomatic prior to the traumatic event and resultant meniscus injury. Degenerative tears are not always symptomatic. When symptomatic, degenerative tears can be treated with non-operative interventions such as oral antiinflammatory medications, physical therapy, bracing and cortisone injections into the joint. Surgery is indicated for degenerative tears if non-operative treatment fails, patient has significant symptoms and MRI findings for a significant unstable meniscal fragment and the knee does not have advanced arthritis.

Greg Lee, M.D., is a board certified orthopaedic surgeon fellowship trained in Sports Medicine at OrthoGeorgia. Dr. Lee specializes in injuries and conditions of the knee, shoulder, elbow, and ankle. Dr. Lee provides care for Workers’ Compensation injuries. He also serves as a team physician for the Academy of Classic Education. He is proficient in Spanish.

Torn Medial Meniscus in a Right Knee (* on Torn and Unstable Meniscus Fragment)

Florida Legislative Update

David Langham, Deputy Chief Judge

The Florida legislative season was not quiet. There were various high-profile bills, conversations, debates, and news coverage. House Bill (HB) 487 was not among them. Yet, its passage is critical to Florida workers’ compensation. Anyone who is a “workers’ compensation health care provider” should have already noticed the bill despite its quiet passage.

This bill fixes the reimbursement process for non-hospital providers. The reimbursement process in Florida has long been within the purview of the “Three Member Panel.” This panel is three people, aptly named, and somewhat singularly focused. Section 440.13(12) enables and defines it. Until 2023, this panel was charged with establishing the schedules for:

“…necessary treatment, care, and attendance provided by physicians, hospitals, ambulatory surgical centers, work-hardening programs, pain programs, and durable medical equipment…”

That was a time-honored process; fee schedules are nothing new in Florida. The recent vexing challenge was in the adjustment or amendment of those schedules since 2016. Then, the Florida Legislature noted that agency rules can create significant costs for Florida citizens and businesses. Officials empowered to adopt such rules are rarely answerable to the Floridian voter. They are more typically appointed officials.

Therefore, in 2016, the Legislature amended section 120.541 to require some information processes and some constraints. First, rules required something called a Statement of Estimated Regulatory Cost (SERC). Think of this as the estimates you see from consumer groups that predict beyond the car’s sticker price to the “ownership costs.” That is an attempt to forewarn the purchaser of the overall cost of a decision to buy a new car (maintenance, insurance, etc.).

Similarly, the SERC is a prediction of how a rule will function and how it may burden this or that person, group, or constituency. Thus, before we buy (enact), we analyze the potential effect. So, what will an idea cost? That is “what is so” or “what is likely?” Once determined, then the statute answers the “So what?” There is a threshold. If a rule is predicted to:

“…have an adverse impact on small business or if the proposed rule is likely to directly or indirectly increase regulatory costs in excess of $200,000 in the aggregate within 1 year after the implementation of the rule…”

Then, the SERC forms must be prepared. Legislative approval of the rule may be required if the impact is expected to:

“Adversely impact economic growth . . . in excess of $1 million in the aggregate.”

“Adverse(ly) impact on business competitiveness . . . in excess of $1 million in the aggregate.”

“Increase regulatory costs, including transactional costs . . . in excess of $1 million in the aggregate.”

This was a valid and appropriate statute to rein in the rulemaking by unelected officials. But, wait… no one thought of the workers’ compensation fee schedules. After the amendments passed, it was determined those schedules were essentially rules and could not be amended without Legislative approval to account for inflation.

This prohibition frustrated the various constituencies. However, efforts to amend the provider schedules met with little Legislative support or enthusiasm. HB 487 changes this. It clarifies that the Three Member Panel will be responsible for the hospital and surgery center fee schedules. But now, the “department” (of Financial Services), essentially the Division of Workers’ Compensation, will adopt “the physician and nonhospital services schedule of maximum reimbursement allowances” each year by July 1. This will not be “subject to approval by the three-member panel,” and does not apply to “reimbursement for prescription medication,” which is addressed elsewhere. These schedules for physician and nonhospital services are specifically now not a “rule,” and thus no longer subject to Legislative approval.

Thus, the fees for physician and nonhospital services will increase immediately as the bill adopts the previously proposed 2020 fee schedule. There will be further developments in successive years under the Division’s supervision. This illustrates the challenges of unforeseen consequences (no one thought of this as a rule in 2016) and Legislative diligence in finding and passing a solution.

David W. Langham, has been the Florida Deputy Chief Judge of Compensation Claims since 2006. His legal experience includes workers’ compensation, employment litigation, and medical malpractice. He has delivered hundreds of professional lectures, published over forty articles in professional publications, and has published over 950 blog posts regarding the law, technology, and professionalism. David is a student, a teacher, a critic, a coach, and a leader. He lives in Pensacola, Florida, with his wife, Pamela Langham, Esq.

Women in Construction Safety

Nicole Ivers, CSP, CIH, CMIOSH

As much progress has been made for women in the workforce, the reality is women are still under-represented in many fields, including construction, and specifically construction safety. Even twenty years into my career, I am still met with curious, often skeptical, looks when introduced as a Vice President of Health, Safety and Environment. The continued perception that the construction industry is not for women is still a barrier.

Let’s be honest… there are probably easier careers. While the industry is open to women, there just aren’t a lot of us in it, so colleagues and mentors are not always easy to find or relate to. On the job, it is challenging to earn the respect of those that think you aren’t credible simply because you haven’t risen up through the hands-on trades. You have to be willing to reach out and find those mentors and other women to talk to and share ideas. Organizations like the American Society of Safety Professionals (ASSP) and Associated General Contractors of America (AGC). You can overcome the stigma of not coming up through the trades by listening and learning from those that did and then applying your safety knowledge to help make them and their activities safer.

Of course, it’s not only about the negatives. In my career, the positive experiences have far exceeded the challenges. There is so much opportunity out there. Safety professionals are in high demand, even more so in construction. This has allowed me employment security throughout my career as it seemed companies were almost always hiring. And, because of this, I’ve been able to move around and up in seniority as new and interesting roles—especially leadership ones—became available. This is relatively true for all those in the profession, not just women safety professionals.

This even took me to Qatar in the Middle East to work on construction for the FIFA World Cup. In addition, many companies have initiatives to diversify and increase their female representation as well as promote women in leadership and/or executive roles. To be clear, I am not saying anyone should be awarded a position purely based on gender. However, these diversity and inclusion initiatives at least ensure women have opportunities to interview and/or be considered for that gender stereotypes and unconscious biases often don’t allow.

Ultimately, I have loved being a champion for others throughout my career in Construction Safety. While I am fiercely protective of the workers I serve, I also enjoy supporting and mentoring other women in the workplace. The more of us who get into these roles and are seen and show success, the more likely it is that other women will see it as a chance for them, as well.

While the glass ceiling for women in this field has definitely not been broken, I take pride that I, and so many of the other women in similar roles, have put a lot of cracks in it.

Nicole Ivers, Global Head of Health, Safety and Environment for Brookfield Properties’ Logistics team, holds a B.S. from Central Michigan University and an M.S. from Wayne State University in Occupational and Environmental Health Sciences. She is a Certified Safety Professional (CSP), Certified Industrial Hygienist (CIH) and Chartered Member of IOSH (CMIOSH). She teaches part-time at Georgia Tech University in Atlanta and is the current President of the Georgia Safety Conference.

Pinnacle Orthopaedics: Fixing Traumatic Injuries

William Terrell, M.D.

Limb Lengthening and Deformity Repair is a very sophisticated orthopaedics sub-specialty and is an inpatient procedure to lengthen the bones in the arms or legs. This is a gradual process that takes advantage of the body’s ability to generate new bones. The whole process may take several months to make sure that the bones slowly increase in length. Likewise, the soft tissues, blood vessels, nerves, and ligaments surrounding the bone should stretch slowly over time and support the lengthened bone.

Patients that need to have limb lengthening/deformity repair if they have bones with a considerable difference in limb length as a result of either trauma or a defect. This also involves a broad range of severity of bones that won’t heal, have formed or healed incorrectly, or have become infected. This also is the case with patients who have had multiple procedures, such as bone grafts, that have not healed properly.

Dr. Terrell has many patient success stories. One enlightening story is about Casey Pickett who was left with a brain injury, a broken pelvis, and two severely broken legs after a drunk driver hit him head on. He survived against all odds and was taken to Atlanta Medical Center. With both legs being broken, the hospital sought out Dr. Terrell to perform his unique external fixation procedure on one of his legs. Then another doctor would repair the other leg with internal rods. This would allow Casey to have one leg to stand on with Dr. Terrell’s external fixator.

It took a year and a half for Casey to fully recover both physically and mentally. Patients who have had traumatic injuries are often angry, frustrated and miserable. Casey said that at first, he was very bitter and depressed. But then he said that his neighbor would come over and hit golf balls with him. The neighbor told him he had to release his hatred for the drunk driver – that he was going to have to “get over it.” Casey credits his friend’s help and says that he “really didn’t start getting better until I had forgiveness in my heart.” There are so many things that impact the healing process. Hope, fear, depression, overall health all matters in recovery. Dr. Terrell says that a lot of times, the whole person needs to be treated, not just the x-ray!

When Casey was healed and had completed treatment, Dr. Terrell told him to go have a life! A year later, Casey came by to visit Dr. Terrell and he brought his newborn baby. This brought Dr. Terrell to tears! He is so proud to see his patients recover and succeed. Dr. Terrell treats his patients like family. And by that means, he has a very large family!

William Terrell, M.D., is a Board Certified Orthopaedic Surgeon with Pinnacle Orthopaedics and specializes in orthopaedic trauma, limb lengthening and deformity correction. He is one of the few limb lengthening and deformity correction specialists in the United States. He has studied internationally and has received extensive studies in the Ilizarov Technique and has also been an instructor on limb lengthening and deformity, both in the United States and abroad.

ABOUT THE PUBLIC RISK MANAGEMENT ASSOCIATION

The Public Risk Management Association (PRIMA) is North America's largest risk management association dedicated solely to the practice of public entity risk management. For three decades, PRIMA has been dedicated to providing hard-hitting, practical education and training for public entity risk management practitioners like you.

There are more than 2,200 PRIMA member entities, of which 1,800 are local governments. These entities realize that membership provides the necessary tools and solutions needed in today's complex and changing risk management environment.

The Georgia Chapter of the Public Risk Management Association (PRIMA) was established in 2004 to provide education, training and professional development opportunities for public sector risk management professionals in the State of Georgia.

Our mission is to enhance the professional skills of our members through:

• quarterly meetings with topics and speakers directly related to the profession

• our annual Educational Series is generally held in spring, an education-intensive multi-day seminar where members learn, network, and meet with private sector representatives from businesses offering services to the membership.

• Networking opportunities throughout the year, allowing members to effectively share and exchange ideas and solutions with their colleagues.

We work to further the best interests of governments, governmental agencies, intergovernmental risk pools, school districts and other special districts in their risk management activities.

LEARN MORE ABOUT GEORGIA PRIMA

We invite you to join us at an upcoming meeting to discover how Georgia PRIMA can contribute to the success of your risk management programs, and benefit your career through our many professional development opportunities. Workplace Health is excited to be a partner with Georgia PRIMA.

Tighter Diabetes Control in Workers’ Compensation Injuries

Eric Patten, RN, BSN

Workers’ Compensation injuries demand continuous management to ensure a successful recovery and prompt return to work. However, for individuals with diabetes, the importance of tight blood sugar control becomes even more critical. Effective diabetes management can lead to significantly improved outcomes and expedited return to work.

Diabetes, a chronic disease characterized by elevated blood sugar levels, affects more than 37.3 million Americans, or just over eleven percent (11 %) of the population, as per the Centers for Disease Control and Prevention (CDC) in 2022.

Achieving tight control involves diligent management of blood glucose levels through medication, diet, exercise, and regular blood glucose monitoring. By adopting these practices, injured workers can reduce the risk of complications, such as infections and delayed wound healing, which can impede the recovery process. Furthermore, well-managed diabetes promotes overall physical well-being, boosts immune function, and enhances mental health, all of which are vital for an injured employee’s successful return to work.

The significance of optimal blood sugar control cannot be overstated. By tightening diabetes control, injured workers can optimize their body’s healing capacity, accelerating recovery from work-related injuries. Additionally, proper diabetes control provides a steady source of energy, enabling sustained productivity during the recovery period.

Tighter diabetes control also reduces the risk of complications associated with the condition, such as cardiovascular problems and nerve damage, which can significantly delay the recovery process. By effectively managing diabetes, injured workers can prevent additional health issues and ensure a smoother rehabilitation period.

Maintaining stable blood sugar levels not only positively impacts physical well-being but also plays a crucial role in reducing stress, anxiety, and depression. This correlation underscores the significance of tight diabetes control in promoting overall well-being and fostering motivation to return to work.

Incorporating tighter diabetes control into the management of workers’ compensation injuries is vital for optimizing outcomes and expediting the return-to-work process. By prioritizing effective diabetes management through lifestyle adjustments, medication adherence, and regular blood glucose monitoring, injured workers can enhance their recovery, minimize complications, and resume their professional lives sooner. It is important to recognize the critical role of tight diabetes control in improving outcomes, ensuring a successful rehabilitation journey, and facilitating a prompt return to work.

Eric F. Patten RN, B.S.N., is the Executive Vice President of Operations & Business Strategies for The Kingstree Group, a leader in the Workers’ Compensation industry for over 24 years, utilizes a consultative approach to lead, create and manage clinical product lines for customers.

The Gambler: Know When to Report the Claim

Jonathan L. Berryhill

Some of the earliest memes circulating during the COVID-19 pandemic centered on Kenny Rogers, the legendary country singer’s most famous for his song, The Gambler, who passed away on March 20, 2020. According to the memes, “If Kenny Rogers folds early, then you know it’s going to get bad.”

Kenny Rogers and his lyrical hero knew when you gamble, the odds are stacked against you. No matter what game you play, the odds always favor the casino. In the game of craps, the odds of a single die landing on any number is one in six, and that number goes up when you add a second die to the game. In poker, the mathematical likelihood of drawing two pairs is one in twenty; a straight is 1 in 253; a full house is 1 in 693; and a royal flush is 1 in 649,737. Slots are mathematically the worst gamble since the odds of winning are roughly 1 in 4,836,032. Even the “safest” casino game, Blackjack, is stacked against the player with less than a five percent (4.8%) frequency of catching a natural twenty-one card count and only a thirty percent (30%) frequency of catching cards in the “firm hold” range of seventeen to twenty.

How does all this gambling relate to your workers’ compensation coverage? Well, if your company isn’t complying with the insurance policy terms for timely reporting claims, then it might as well be in Vegas rolling dice. The odds are decidedly against you.

There has been a decided uptick in companies electing to handle a work injury claim in-house, at least until the medical treatment and/or continued wages get costly. The idea is that by not reporting the claim and directly paying the medical and continued wages to the injured employee, it offers an opportunity to avoid a negative hit to the Experience Modification Rate (EMR) for a reasonable amount of money. After all, managing a claim for a trusted, long-term employee surely won’t lead to problems—economic or legal—down the road…. or will it? You may hit the jackpot for that one claim, but the odds are not favorable. Eventually, you will roll craps. And, when that happens, the cost of playing this game goes through the roof.

Under the terms of your workers’ compensation policy, your company is obligated to immediately provide written notification to the carrier of any injury to an employee, regardless of severity. This means any time there is a known work-related injury, you must report it. This includes minor cuts and scrapes that don’t result in any missed time from work to those lost-time claims that, although minor in appearance at the outset, ultimately result in significant missed work.

Your workers’ compensation policy more-than-likely states that under no circumstances may your company settle, pay, or, in any way, dispose of a work-related injury claim on its own. If your company makes a voluntary payment (medical treatment, continued wages, etc.), assumes an obligation to pay for an injured employee’s medical treatment, authorizes treatment by a doctor or clinic, or pays the employee for time missed from work while recovering from an injury, then the insurer may not be responsible for the claim and could later deny coverage completely.

Under the terms of your policy, if a claim isn’t reported timely; if medical treatment is authorized by your company or paid for directly (or paid through regular health insurance); if salary or wages are paid to the employee for time away from work recovering from an on-the-job injury; if a claim is “accepted” as compensable by the employer; etc., then the insurance company may have the contractual right and authority to refuse to cover the claim when it is eventually reported. If your company doesn’t follow through on its responsibilities under the policy, then the insurance company may deny coverage to your company for the claim and may not be obligated to pay any benefits on behalf of your company to the employee or their medical provider(s).

Handling a claim outside your workers’ compensation coverage comes with big risks. What may seem like a minor injury, at first, may ultimately require surgery. MRIs, CT scans, and surgery costs (such as the hospital, anesthesiologist, surgeon, and prescription medications) can run into the tens or even hundreds of thousands of dollars. In extreme cases, medical treatment financial obligations can extend above a million dollars.

Keep in mind, too, that health insurers usually have an exclusion for work-related injuries. If the health insurer determines the medical treatment they are paying for is due to a work-related injury, they may stop payment and/ or demand repayment of the medical charges already paid. If the charges by a medical provider aren’t paid in a timely fashion, then your state laws may allow the medical provider to assess a penalty for non- or slow payment.

On top of the medical exposure, the employee is entitled to weekly compensation payments while out of work recovering from the injury. If the employee has a permanent disability, then the employee is entitled to a weekly benefit payment for that disability even after they recover from the injury. And, if a court determines that no workers’ compensation coverage was in place for the employee’s accident (which could happen if your coverage

is denied), then the court could award damages or fines as a penalty. There are occasions when the indemnity exposure on a claim also exceeds a million dollars.

Your workers’ compensation insurer and its adjusters are in the business of reducing claim costs and minimizing time away from work for your injured employees. They have vetted the best available medical providers across your state for injured area of the employee’s body. These medical providers are familiar with the workers’ compensation system and its requirements. Your workers’ compensation insurer also has negotiated contracts with these medical providers and pharmacies to ensure the lowest costs possible for providing authorized medical treatment or prescription medication.

In many cases, your workers’ compensation insurer negotiated rates are significantly lower than the medical fee schedule established by your state. Further, your insurer has trusted relationships with nurse case managers, physical therapy facilities and such to ensure open communications with medical providers and to facilitate the best outcomes possible.

The insurer and its claims professionals have years of experience handling workers’ compensation claims involving complex medical conditions. Relying on that experience, your insurer and its claims team occasionally will challenge whether or not a medical condition the doctor wants to treat is actually the result of your employee’s on-the-job injury. On other occasions, your insurer may challenge the type of treatment the physician recommends. Your insurer and its claims professionals are also knowledgeable about the actual value of indemnity/vocational benefits owed to your employee as they battle claimant attorneys to obtain a reasonable settlement or, if required, a court decision.

Simply stated, the financial stakes are high if your company decides against turning in a workers’ compensation claim with the idea you can beat the system. When it comes to reporting injuries, your company’s best bet is to fold early and report the claim. The odds are too steep to gamble.

Jonathan L. Berryhill is the senior partner at Berryhill & Mitchell, PC, representing self-insured employers, self-insured funds & members, and insured employers in workers’ compensation and related matters throughout Alabama for over 25 years. He is the past chair of the Alabama State Bar WC committee and the international DRI WC committee and is currently president of the Alabama Workers’ Compensation Defense Lawyers Association. He holds the highest rating for attorneys with Martindale (A-V) and has been voted a Super Lawyer & Best’s Lawyer of the Year in the workers’ compensation field.

A Message from the Chairman

Ben Vinson, Chairman and Chief Appellate Judge

I hope everyone had a nice summer and is looking forward to an exciting fall. On behalf of the State Board of Workers’ Compensation, I am pleased to report that we are having a successful year in 2023 across all Board operations and proceedings. We continue to stay busy with mediations, hearings, appeals, and settlements. The system overall seems to be healthy and stable, so we will continue our mission to keep it that way.

This spring, the Board enjoyed hosting our regional seminars across four cities with lots of participants. I want to thank the Public Education Committee of the Chairman’s Advisory Council for organizing an entertaining program for the regional seminars that focused on useful information and tips on important topics including the panel of physicians, light-duty/return to work, and recent court decisions. We had a great time in Tifton, Alpharetta, Cartersville, and Savannah this year putting on the show and interacting with workers’ compensation professionals. We appreciate everyone who participated by sponsoring, exhibiting, speaking, and/or attending.

On the—always interesting—legislative front, the Georgia General Assembly convened the 2023 Session on January 9 and adjourned Sine Die on March 29. Congratulations to Speaker Jon Burns and Lieutenant Governor Burt Jones on their new leadership positions. I appreciate their friendship and support.

Two bills passed into law this year impacting the workers’ compensation system. HB 480 by Representative Lehman Franklin clarifies the law on dependency benefits when there is a deceased employee and increases the maximum amounts for TTD, TPD, and death benefits based on continued rising wage rates in Georgia. SB 91, by Senator Clint Dixon, extends the sunset date from 2023 to 2025 for the Subsequent Injury Trust Fund and its board of trustees. In addition, HB 451, by Representative Devan Seabaugh, establishes an insurance program to assist first responders with post-traumatic stress disorder conditions. It was introduced and will be eligible for consideration next year so stay tuned in for more on that one.

Now, I want to alert you to an important change to our appellate procedure. As of July 1, 2023, a party wishing to appeal from a decision of the Appellate Division of the Board should file directly with the superior court not with the Board as in the past. Our appeal statute O.C.G.A. § 34-9-105 was amended last year by the General Assembly as part of the new Superior and State Court Appellate Practice Act, which repeals and replaces other statutes with a unified “petition for review” procedure for appealing cases from a lower judicatory body such as the Board. Please refer directly to O.C.G.A. § 34-9-105, Board Rule 105, and the Superior and State Court Appellate Practice Act for specific requirements and procedures.

To be clear, effective July 1, 2023, if you are not satisfied with an award or order of the Appellate Division of the State Board of Workers’ Compensation, you must file an appeal (petition for review) with the superior court of the county in which the injury occurred, or if the injury occurred outside the state, with the superior court in which the original hearing was held, no later than twenty (20) days from the date on the award or order. A copy of the petition for review shall simultaneously be filed with the Board electronically through ICMS, which satisfies the statutory requirement that a copy of the petition be served on the clerk of the Board. We certainly hope word of this change spreads so no one files an appeal in the wrong place.

Have a great finish to 2023 and I look forward to seeing you at our regular events this fall.

Ben Vinson was appointed Chairman and Chief Appellate Judge of the State Board of Workers’ Compensation by Georgia’s Governor Brian Kemp in May 2021. He previously served as Director and Appellate Division Judge for the Board, appointed by former Governor Nathan Deal in July of 2017. In addition to hearing Workers’ Compensation cases on appeal, Chairman Vinson shares responsibility with Judges McKay and Bahl for governing the state agency, which includes regulatory, policy, and operational matters.

Pay and Investigate

Kristofer Vander Pyl

It is usually smooth sailing in our workers’ compensation industry, but every now and then the First District Court of Appeals (FDCA) decides it wants to upend our quietude. That is what recently happened with the FDCA’s latest Churchill v. DBI Services (1D21-3199).

When a claim reaches a Carrier’s desk, three choices become available: 1) accept the claim, 2) deny within fourteen (14) days, or 3) Pay and Investigate. This third option allows the Employer/Carrier to defer deciding on compensability until enough information is gathered to deny within 120 days. This goes to the compensability of the accident itself, but also of every benefit that is later requested by the Claimant.

The one caveat is the Employer/Carrier must pay all the medical bills and Indemnities as if the claim was compensable. When used wisely and in close collaboration with your favorite Defense Attorney (preferably one at Eraclides Gelman), it is a great arrow in your quiver.

The law since the FDCA’s 2006 ruling in Checkers was that the Employer/Carrier could utilize the 120-day option regardless of whether the 120-day letter had been sent to the Claimant or not. This was good. Think of the situation where the employer knows about the injury and authorizes care but does not apprise the Insurance Company until say two months later.

In Florida, the Employer’s knowledge is input by the Carrier. The clock in this scenario began ticking when the Employer sent the Claimant for care. Under Checkers, although it was too late to deny within fourteen days, we could always deny within four months and shut the claim down by invoking the Pay and Investigate option, without worrying about when the letter was sent.

Churchill ends this; the 120-day letter must be sent to the Claimant or the claim is deemed accepted. The letter does not need to be sent with the first payment/provision of a medical benefit, but it needs to be sent “as soon thereafter as reasonably practicable”. Here, 59 days was too late.

So, where does that leave things?

• Employers – do not wait to report the accident. If you send the Claimant for care without letting your Carrier know, the clock has been ticking and if fourteen days pass, the claim can not only no longer be denied outright, but also arguably now, if you wait too long, cannot be denied within 120 days anymore. A Judge will rule the letter was not sent to the Claimant when it should have.

• Adjusters – when the accident reaches you timely, confer with your defense attorney to make a prompt decision on compensability. If you cannot deny it immediately but believe the claim warrants further investigation, send the 120-day letter on the fifteenth day. A Judge will likely be satisfied and consider that reasonable. When the decision relates to a subsequent benefit that is being sought by the Claimant, send the 120-day letter immediately after the benefit in question is recommended or a Petition for Benefits is filed. Lastly, for those claims that are already underway where you are paying and investigating but have not sent the letter out yet, do it now.

The other side is eager to litigate this and get a juicy fee; reach out to me at kvanderpyl@eraclides.com and I will gladly help you prevent that from happening.

Kristofer Vander Pyl, Associate at Eraclides Gelman, brings expertise in the workers’ compensation industry, assisting employers and carriers with strategic solutions and effective claims management in Florida.

A Team-Based Care Approach for the Catastrophically Injured Worker

Sharon Noe

The top five catastrophic work-related injuries treated include: spinal cord injuries, traumatic brain injuries, amputations, burns, and multiple traumas. Upon stabilization at a trauma center or other short-term acute care hospital, a Specialty Hospital, such as Landmark, evaluates and admits the injured worker and begins to navigate the healing journey to recovery.

Our primary focus at Landmark is providing patient-centered, cost-effective care with identified, desired endpoints, which can be incredibly challenging and yet immensely rewarding.

Our team-based care model begins with active collaboration that:

1) Identifies which individual skills are most critical to patient success at each stage

2) Becomes a foundation and a live process to constantly evolve and change based on success and setbacks

3) Utilizes the core experience of the team as well as the individual talents of team members

4) Is communicated to, and agreed upon by all shareholders including patients, families, and the worker’s catastrophic case manager

5) Includes daily communication to address the frequent changes in the condition of the newly injured.

Team members assess each patient individually and develop treatment plans for each specific patient, indicating who will proactively need to be engaged and at what point during the treatment process. At Landmark Hospital, those services would include:

• Daily coverage as needed by a qualified intensivist, and multi-specialty physicians including Pulmonology, Infectious Disease, Nephrology, Wound Care, Psychiatry, Neurology, Plastics, Optometry, and Surgery

• Therapies including PT, OT, SLP, RT, Neurocognitive and/or Neurobehavioral, Adaptation, Pharmaceutical, Registered Dietician, and Social Work

• Registered Nurses with ACLS training who are capable of caring for all components of catastrophic injuries and able to perform codes on-site as needed.

• Appropriate equipment such as state-of-the-art Hamilton Ventilators™ which allow the intubated patient to speak, Veriflo™ irrigating wound vacs, Tablo™ dialysis machines, and all other devices thoughtfully incorporated into daily treatments.

Our team-based care includes a “no-egos,” all-hands-on-deck approach. Physical therapy may need to interact with the patient daily for longer sessions while occupational therapy appears as co-treatment. Speech and respiratory therapists work together on ventilated patients or airway impairments to progress patients aggressively but safely, while swallowing abilities are evaluated. Neurocognitive therapy coaches the entire team on effective modalities for communication not only with the patient, but with each other. Pharmacy collaborates with dieticians and physician providers to evaluate formulary and non-formulary solutions to tube feeding, pain management, and infection control. Neuropsychologists often work with social workers to determine opportunities for adaptation and participation in family meeting updates. The Workers’ Compensation case manager plays a key role in the collaborative experience and guides the team to desired endpoints. He/she meets with the treatment team either remotely or on-site as often as desired to provide guidance and advice regarding treatment interventions or equipment needs such as DME, as well as ongoing plans for the next stage of catastrophic injury management.

Navigating the recovery of the catastrophically injured worker from the moment the patient is referred to Landmark Hospitals and eventually to a community-based setting or lower level of care provider requires a great deal of collaborative effort and experience. Our team-based care approach provides real-time measurement of outcomes to facilitate the next set of recovery goals and leads to remarkable success stories for catastrophically injured workers and families.

Sharon Noe is the SVP of Business Development at Landmark Hospitals. She has over 30 years’ experience in Healthcare management including Operations, Mergers/Acquisitions and Strategic/Business Development for Inpatient and Outpatient post-acute service lines.

Possible New OSHA Rule May Help Unions Organize

Phillip B Russell

The U.S. Occupational Safety and Health Administration (OSHA) is working on a proposed rule that would eliminate the limitation on who can participate in an OSHA inspection of a workplace and expand the definition of “a third party.” The broader definition could include third parties who are community activists and union representatives unassociated with the workforce in an inspection location. Such regulatory changes could have major implications for employers being inspected by OSHA.

The OSHA regulation 29 C.F.R. § 1903.8(c) states:

The representative(s) authorized by employees shall be an employee(s) of the employer. However, if in the judgment of the Compliance Safety and Health Officer, good cause has been shown why accompaniment by a third party who is not an employee of the employer (such as an industrial hygienist or a safety engineer) is reasonably necessary to the conduct of an effective and thorough physical inspection of the workplace, such third party may accompany the Compliance Safety and Health Officer during the inspection.

In February 2013, during the early months of the second term of the Obama Administration, a standard interpretation related to OSHA regulations at 29 C.F.R. § 1903.8(c)—later known as the “Fairfax Memo”—was issued. The Fairfax Memo was the tool the administration attempted to use to allow union representative participation in OSHA inspections at nonunion workplaces.

That standard interpretation answered two questions from the United Steel, Paper and Forestry, Rubber, Manufacturing, Energy, Allied Industrial, and Service Workers International Union. The standard interpretation was used to permit union representatives, including union organizers, to participate in OSHA inspections. In 2017, faced with mounting legal challenges, OSHA officially rescinded the “Fairfax Memo.”

In the Biden Administration’s Fall 2022 Unified Agenda of Regulatory and Deregulatory Actions, published on January 4, 2023, OSHA announced it was planning to publish a notice of proposed rulemaking (NPRM) related to 29 C.F.R. § 1903.8(c) stating:

This rulemaking will clarify the right of workers and certified bargaining units to specify a worker or union representative to accompany an OSHA inspector during the inspection process/facility walkaround, regardless of whether the representative is an employee of the employer, if in the judgment of the Compliance Safety and Health Officer such person is reasonably necessary to an effective and thorough physical inspection.

The announcement in the Fall 2022 Regulatory Agenda suggests an alteration would be made to the language of the rule eliminating the limitation on who can participate in an inspection, expanding the definition of “a third party who is not an employee of the employer (such as an industrial hygienist or a safety engineer) [who] is reasonably necessary to the conduct of an effective and thorough physical inspection of the workplace” to include community activists and union representatives not associated with the workforce in the inspection location.

If such an alteration to 29 C.F.R. § 1903.8(c) were adopted, the run-of-the-mill OSHA inspection could forever change in several ways:

Community activists and union representatives would gain, through participation in an inspection, useful knowledge or relationships to facilitate an organizing campaign. Currently, third parties cannot come onto an employer’s premises to organize employees (although the National Labor Relations Board is attempting to change this rule), but this would give organizers and community activists such an opportunity. Union organizers or community activists could gain access to an employer’s premises during business hours and interact with employees while accompanying an OSHA compliance officer. Ostensibly, they could also participate in OSHA’s private interviews with employees, which would give union organizers a captive audience.

During organizing campaigns, the number of OSHA complaints raised at a workplace typically increase. Union organizers frequently claim an employer does not care about workers’ safety and the union can make

the employer improve safety. With modifications to the rule, union organizers would gain the additional persuasiveness of having their arguments buttressed by the act of accompanying a government official in a workplace to ensure it is safe and healthful. It is anticipated that the rule change would allow representatives from another union that wishes to unionize employees outside of the current bargaining unit or supplant the union that has enjoyed a benevolent relationship with the employer.

Having an outside special interest or union activist at a worksite during an inspection may strain the employer’s ability to cast its workplace in the most favorable light. OSHA only publicizes citations and penalties—conditions OSHA contends violate its safety standards. Except for inspections resulting in large fines, fatalities, or catastrophes, most OSHA inspections receive little to no public attention, even in terms of OSHA press releases. Community or union activists may have a different agenda relative to reporting on the details of an inspection or creating reputational harm to employers. Community activists may want to draw attention to conditions that may appear alarming to the public, even when the conditions follow best practices in the industry and are not considered violations of OSHA standards.

For example, if representatives of an environmental group were allowed on-site, they might be permitted to conduct their air sampling or have access to OSHA’s air sampling information seldom released in the public domain absent a Freedom of Information Act request. If a community activist or union representative were to have access to that information, employers could expect the information to be shared in print, at community meetings, or at any time the employer was involved in a regulatory matter, whether tied to an inspection or not.

Community activists and union activists could impact the results of OSHA investigations as shown in citations. While OSHA’s Field Operations Manual and established law discourage OSHA compliance officers from engaging in outcome-based inspections, the presence of unrelated third-party activists could create pressure on compliance officers to reach certain outcomes that align with activists’ concerns.

Participation by outside activists may increase the risk that an inspection will broaden with a community activist’s or union organizer’s help in finding probable cause for s scope expansion. Employers may experience more difficulty controlling physical or visual access to areas not involved in the incidents or programs that brought OSHA on-site. An activist may provide a greater breadth of knowledge for an inspection and educate and cue the OSHA compliance officer to other areas and possible violations.

An actual rule will require time for OSHA to develop, go through a corresponding notice and comment period, and publish before becoming effective. Meanwhile, given this regulatory agenda item exists, it would not be unusual for activists and others to push back on inspections that do not include them. Employers may want to note that the proposal under consideration is not the current OSHA policy.

Phillip B. Russell is an OSHA attorney with the law firm Ogletree Deakins Nash Smoak & Stewart PC and a member of the Workplace Safety and Health Practice Group. He has represented employers in hundreds of fatalities and other cases nationwide.

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Helping the children of seriously or fatally injured workers reach their educational goals

HAD A GREAT TIME AT THE GWCA GOLF CLASSIC!

JOIN US IN 2024 ON MONDAY, JUNE 3RD!

Old Dogs New Culture: Building and Sustaining an Interdependent Safety Culture

Benjamin Martin, M.S., ASP, Christina Lindsay, B. A., and Dr. Christopher Downing, Jr., Ph. D.

Learning something new is rarely enjoyable, yet we continue to do it as technology advances. Most of us have at least experienced that through adapting to things like social media apps, online meetings, and the latest technological advancements for process improvement. Understanding the benefits of teaching “old dogs” new tricks can benefit both the organizational bottom line (revenue) and the organizational culture. Retraining old dogs or “experienced” employees can further enhance the mindset of safety culture in an organization.

While the intersection of safety operations and staying current with technology might seem counterintuitive, the symbiosis of this relationship has always existed. Audits and inspections, historically, were completed with paper and pen, while trainings were performed using a distribution of booklets. However, due to the pandemic and other process improvement revelations, we have realized the potential of technological advances.

Automated inspections encourage attention to detail and video or interactive training modules increase the consistency of information and processes being taught. Hands-on training in a controlled environment enhances job performance and safety knowledge, as well as situational awareness. Embracing technological advances increases opportunities for identifying improvement areas, encouraging collaboration, and providing more realtime feedback in developing a safety culture. However, the ever-changing technological advancements in the workplace do not replace the advantages of experienced employees.

In another application, the tech boom of the 90s introduced cost-effective education methods for enhancing “seasoned” employees’ computer literacy by slowing the pace of training, using peer educators, and utilizing smaller classes. This idea has been used in the evolution of the ways we communicate with each other. Tenured employees acclimate to communicating via social media and other applications to teach and mentor the growing workforce. A great example would be to leverage experienced team members when learning contemporary safety audits and inspection procedures for new equipment. Using tools such as video conferencing allows organizations to maximize expertise to provide the most benefit.

Research in psychology has identified learning styles, skill diversity, and intrapersonal needs as important variables to consider when acclimating to new processes. A similar approach can also be implemented into peer-to-peer coaching processes (i.e., Behavior-Based Safety) as opposed to a top-down approach, thus fostering community, belongingness, and trust. Meeting such intrapersonal needs improves the acceptance and efficiency of corrective feedback, a pivotal component for a successful peer coaching culture.

Old dogs can also learn from obstacles themselves. Teaching tenured employees helps them stay ahead of the curve and enables them to step into leadership roles to emulate, mentor, and, thus, maintain a safety culture. Finally, and most importantly, we learned we can’t hire a caring culture mindset. It is something that is cultivated in an organization with good leadership.

Yes, old dogs can learn new tricks if we identify opportunities for them to work interdependently and how they add value to the millennial workforce. Also, they can influence and teach a new culture or mindset, or a total safety culture. Organizations need to identify such agents of change and empower them to be successful mentors. We learned this method is effective. For example, similar to a scaffolding method from a construction site, we know stronger supports on the bottom enhance and enforce structural stability as it grows and becomes more fragile.

Benjamin Martin is a Safety and Organizational Development Consultant with over a decade of experience in manufacturing, government, and construction, focusing on using humanistic behaviorism techniques to motivate a safe working culture.

Christina Lindsay is a business owner and manager with degrees in Business Administration and Accounting, having worked in company development and human resources for twenty years, growing several multi-million-dollar companies predominately in the medical field.

Christopher Downing, Jr., Ph.D., is an Assistant Professor in the Industrial/Organizational Psychology program at Valdosta State University. His research interests focus on improving the safety and well-being of employees in the workplace, providing various consulting services from safety to workforce development.

Industry Spotlight: Roberta Mike

Madison Rawls, Workplace Health intern

Workplace Health: Roberta, thank you for your time and expertise. If you could share one thing with a new adjuster to the industry, what would it be and why?

Roberta Mike: As of July 2023, I have forty-two years in this business. I had a realization moment a couple of months ago when my manager asked, “Are you leaving us anytime soon?” Taken aback, I said, “No.” My manager said, “I hope you give us proper notice so we can be respectful about your retirement.” That was when it hit me. This was a decision I had to think about.

That was when I created a Facebook Group to talk about the most important thing in our industry: mentorship. The Workers’ Compensation Career Mentorship Group was born with the goal of educating, recruiting, and encouraging new adjusters to consider a GREAT career in Workers’ Compensation across the country, not just in Georgia. Currently, we have 600+ members and the feedback has been exceptional. It all circles back to encouraging mentorships in a new adjuster’s career. This should include seasonal claim adjusters, attorneys, and claims managers (who are not dictators), as well as other industry people who are experienced and want to help others succeed.

Workplace Health: How important is mentorship to the overall Workers’ Compensation industry?

Roberta Mike: We’ve recently suffered a Great Resignation. We’ve known for some time to prepare for a great number of people retiring… and then the pandemic hit. It doubled/tripled the loss of good, seasoned adjusters. The professionals that left the industry took their experience with them. So, everyone is scrambling to find adjusters, the current adjuster evaluated their careers and realized their valuable experience. The adjusters are going to various companies for better pay and opportunities. The industry hiring has been challenging because everyone wants to work remotely. If the company isn’t offering remote work, the new adjusters are not interested.

Workplace Health: Remote work is quite important to many people. Is it a time management thing, a control issue, or a cost matter?

Roberta Mike: The reality is, in a lot of states—even here in Georgia—it takes about two and a half hours to travel roundtrip to work. Workers now know they can use that time better working from home. They are saving money on gas, lunch, and the time spent getting dressed. There are pros and cons, of course, but that’s how a lot of people look at it because they can’t stand sitting in traffic.

Let’s face it. Commuting frustrates you, makes you irritable, and you can have trouble focusing since it takes about half an hour to settle in upon arrival to work. Remote work and work-life balance have become more popular because we didn’t realize a lot of people have lost family members, or they’re taking care of other family members, small children, or grandchildren and they need flexibility in their lives and the employers are responding to that.

Workplace Health: What advice would you give to someone who wants to pursue a career in your profession?

Roberta Mike: First and foremost, I would tell them to do your research about a career. Is this something you want to do? Can you see yourself doing it long-term? They need to review the criteria for their career. Some of the biggest things in this job are communication, strategy, and being an out-of-the-box thinker. If those things don’t interest you, then don’t apply for this career. You’ll just be straddling along and your work ethic will reflect that. Communication by phone, in person, or virtual is a must.

When I talk to people, they talk about money… what’s the pay? I stop them and tell them the pay will come, but is this your passion to be the best you can be? You’ll get the pay. But ask yourself the right questions. Are you a people person? Do you like to communicate? Are you inquisitive? Then, this can be the career for you. As soon as you make a decision, start branding yourself. Adjusters like to sell themselves. If you sell yourself with the strong work ethic you have, then more and more clients will want to work with you and it shows they have found value in the relationship.

Finally, get your education. All employers offer educational opportunities and training. They offer classes for reading, writing, grammar, software programs like Microsoft Word and Excel, getting your designations, etc. It’s all about relationship building.

Madison Rawls is a soon-to-be Georgia Southern graduate in the fall obtaining a Bachelor of Science in Public Health with a concentration in Health Education and Promotion, as well as a minor in Business Finance. She seeks to expand essential skills while facilitating company growth, spreading awareness about Workers’ Compensation and promotion of health through different social media platforms. Her goal is to take WorkPlace Health magazine to a whole new and advanced level targeting audience engagement with the priority of reducing risk and promoting workplace health.

Shoulder Injuries in the Workplace, Diagnosis, and Treatment

John J. Greco, M.D.

Several types of injuries that you see in the workplace include rotator cuff injuries, SLAP injuries, anterior/ posterior/multidirectional instability, fractures and associated pathology, specifically adhesive capsulitis and arthritis. Most commonly, outlet impingement, the precursor to rotator cuff tears, partial or complete rotator cuff tears, can occur from this injury. This is seen with an associated condition called subacromial space narrowing. So, the situation could be acute or chronic, meaning that you could have a situation where you do not see any problems, there is no history of issues, and then, suddenly, you have an injury, and then usually have a significant problem with rotator cuff tearing, rotator cuff injuries.

For example, there is a patient who has pain, weakness, and radiation of discomfort to the arm and the deltoid. What are the steps toward diagnosis and treatment:

• EXAMINATION OF ROTATOR CUFF AND PHYSICAL EXAM: Check for painful arc of motion, abnormal scapulothoracic motion, glenohumeral motion, Hawkins and Neer impingement testing, Speeds and crossover adduction testing.

• IMAGING: After a full history and physical is done, you want to get imaging, X-rays, AP, lateral, axillary, and outlet views are what you want to see. The MRI is still the gold standard for analysis of shoulder pathology.

• TREATMENT OPTIONS: Nonoperative management certainly should always be considered the standard of care initially. Nonsteroidal anti-inflammatories, physical therapy with modalities, and cortisone injection are all considered gold standard of care initially.

• NONOPERATIVE MANAGEMENT GOALS: Manage symptoms with conservative care in order to return patient back to work. Goal is returning to the same state of function as before injury.

• TREATMENT OF THE ROTATOR CUFF: Proceed by addressing the articular cartilage, evaluating pathology within the biceps, and continue with an acromioplasty and AC Joint resection as warranted

• SURGICAL MANAGEMENT: You repair the cuff if it is torn more than fifty percent (50%) of its footprint. Repair is either open, mini-open, or arthroscopically done, as per surgeon’s preference and tear type.

The bottom line…You want to repair rotator cuff tears. Surgery should proceed sooner than later. If they develop fatty infiltration or poor blood supply, there is a significant increase in repair failure. What is done with a chronic rotator cuff tear that is massive? Often, it is irreparable. Chronic tears with retraction are not repairable. The treatment for this is nonoperative or operative management. Postoperative rehabilitation after rotator cuff surgery requires immobilization and a sling for 4 to 6 weeks. Personally, I want people to move very quickly so, although I do not want them to sleep without the sling or raise the arm in an abduction manner for the first 4 weeks after repair, I do want them to be moved passively beginning on post-op day 1. The goal is to reach full passive range of motion within 4 weeks, while continuing strengthening over the next 8 to 12 weeks, with modified duty at roughly 2 weeks postop.

The biggest complication we see is Adhesive Capsulitis. Treatment? Therapy is the mainstay. Injections are minimally beneficial. Nonsteroidal anti-inflammatories are also minimally beneficial. Manipulation under anesthesia, arthroscopy is sometimes warranted. Post operative patience is a virtue, as long as patient makes progress with Physical Therapy and continued conservative care.

John J. Greco, M.D., has been a member of The Orthopaedic Center for over 24 years. He is board-certified in orthopaedic surgery and sports medicine. Over the years, he has developed a special interest in arthroscopic and open reconstructions of the knee and shoulder while utilizing the most up-to-date technology. He implements the latest literature to develop a treatment plan that will employ both surgical and non-surgical techniques to assist the patient with obtaining the best possible outcome. Currently, he is involved in research that studies the long-term effects of biocomposite anterior cruciate ligament and posterior crucial ligament screws. He also serves as the head team physician for Alabama A & M University, the Huntsville Havoc hockey team, as well as overseeing numerous North Alabama high school athletic programs.

Biceps Tendon Injuries

Mark Snoddy, M.D.

The main function of the biceps tendon is elbow flexion and forearm supination (turning the palm toward your face), two key motions in any lifting activity. Given the propensity for on-the-job lifting— from heavy laborers to office workers—any employee can be at risk. While strains occur from overuse and repetitive activities, partial or complete ruptures are often the result of a single, heavy-lifting event with sudden biceps muscle contracture.

Since the biceps tendons attach the biceps muscle to the bones in the shoulder and elbow, biceps tendon injuries can occur at either location, with shoulder or elbow pain being a potential indication of biceps pathology. For biceps strains, the tendon becomes inflamed from overuse, causing soreness with lifting activities. Occasionally, with partial or complete tendon rupture, a painful *pop* occurs, followed by weakness, bruising, and arm deformity.

Biceps tendon tears at the shoulder make up ninety percent (90%) of biceps tendon injuries and are often the result of wearing down and fraying of the tendon that occurs slowly over time. For this reason, this is often seen in older individuals. Repetitive overhead activities can additionally weaken the tendon, leading to an increased risk of rupture. Ruptures of the biceps tendon at the elbow make up ten percent (10%) of all biceps injuries and have an incidence of five cases per 100,000 per year. These injuries are more common among forty to fifty-year-old men and eighty-six percent (86%) of the time is the dominant extremity. Additional risk factors for biceps tendon ruptures include smoking, corticosteroid medications, and pre-existing shoulder pathology.

In the clinic, a patient’s injury history and physical exam can confirm the diagnosis for the treating physician. Visible deformity in the form of bruising and a “Popeye” deformity (see attached image –UpToDate) from the ruptured and retracted tendon can be present in complete tears. Partial ruptures can be more subtle and rely on provocative exam maneuvers. Oftentimes, advanced imaging such as magnetic resonance imaging (MRI) is needed to assess for partial versus complete tendon tears or associated injuries, such as rotator cuff tears or shoulder impingement.

In patients with strains or partial tears, nonsurgical management consists of anti-inflammatories medications (NSAIDs), physical therapy, activity modification, ice, and steroid injections. Additionally, complete biceps tendon tears at the shoulder can be managed with conservative measures initially.

For complete ruptures at the elbow or those that have failed conservative treatment, persistent biceps pathology can be debilitating, result in long-term weakness and arm fatigue, and can inhibit a return to a prior level of activity. For these patients, outpatient surgery is performed to reattach the tendon allowing for returned strength, improved endurance, and deformity correction. Immediately after surgery, a patient will be placed in a shoulder sling. However, patients will begin physical therapy within a few weeks of surgery to assist with recovery of strength and joint range of motion. While patients can return to light duty early in the recovery process, a full return to activities is expected in the three-to-fourmonth range.

Mark Snoddy, M.D., is a board-certified hand, shoulder, and elbow surgeon at Augusta-Aiken Orthopedic Specialists. He earned his medical degree from the Medical College of Georgia and completed orthopedic surgery training at Vanderbilt University. He completed a fellowship in hand and upper extremity surgery at Harvard University, training at Brigham and Women’s, Massachusetts General, and Boston Children’s hospitals.

Chaos is Coming: What Can We Do?

C. Wade McGuffey, Jr., Esq.

A well-trained and experienced workforce is essential to all industries; the workers’ compensation insurance industry is no exception. A study looking at the history of the training and experience of workers’ compensation adjusters and examiners reveals a significant decline in the amount of training currently available to adjusters and examiners who are considered “Novices” since they are new to the industry.

These Novices are expected to use computer programs to perform their jobs, but such computer programs were developed with the expectation that the users would be well-trained and experienced. At the time the computer programs were being developed, there was a large pool of well-trained and experienced adjusters who are now senior professionals.

These senior professionals began their careers from the 1980s through the 2000s when most major insurers had training programs to educate adjusters. The new employees were required to attend training programs, often for weeks at a time. The programs were conducted under names such as Claims College and Workers’ Compensation College. The result was a proficient and skilled large group of claims adjusters who then developed considerable experience over time in adjusting workers’ compensation claims.

Many of these formal training programs were discontinued by 2007 at the start of the Great Recession. Many people thought because there was such a large pool of well-qualified and experienced adjusters that the only training needed was on the internal policies and procedures of the particular insurance company. In addition, during the Great Recession, the number of workers’ compensation claims decreased dramatically, reportedly by twenty-five percent (25%) or more, leaving some senior professionals without a job.

Adjusting workers’ compensation claims requires the ability to analyze and understand medical records, to correctly apply legal standards, and to use investigative skills to see the larger picture to conclude claims correctly and to avoid issues and penalties. Novices have neither the training nor the experience to do so. To further complicate the situation, many adjusters are required to manage case files in multiple states, often including claims in ten to twenty different states. The workers’ compensation system varies significantly from state to state, and it is neither quick nor easy for Novices to train and gain sufficient experience to develop the ability to handle workers’ compensation claims in multiple jurisdictions.

Following the COVID-19 pandemic, the number of senior professionals resigning or retiring (the “Great Resignation”) accelerated. As a result, an increasingly larger part of the pool of adjusters is now made up of Novices. Efficiencies are down and turnover is up. State boards and commissions are reporting significant increases in errors and failure to comply with regulatory requirements.

The Great Resignation has impacted employers in all industries. Fewer workers are now available to do more work, leading to an increasing number of workers’ compensation claims. New hybrid and work-from-home programs present additional challenges. The failure to address these changes could have disastrous effects on injured employees and the cost of workers’ compensation coverage.

Because of these issues, some state boards and commissions are developing their own training programs. Insurance companies need to reinstate comprehensive training programs or support the available training programs, both financially and by encouraging their employees to attend the programs.

C. Wade McGuffey, Jr., leads the multi-state workers’ compensation practice of Goodman McGuffey, LLP. He is licensed in Georgia and Florida. He is a member Georgia State Board of Workers’ Compensation Chairman’s Advisory Council.

Coaching and Mentoring Increase Employee Engagement and Well-being

Don Lang

In the Gallup Organization’s 2022 report, employee engagement—the level of involvement and enthusiasm of employees in their work and workplace—was at a dismal thirty-three percent (33%). According to Gallup, employees can become engaged when their basic needs are met, they have a chance to contribute, and when they have a sense of belonging and opportunities to learn and grow. Organizations in the top decile of engagement outperform their peers by 147% of earnings per share and have ninety percent (90%) better growth than their competitors. Clearly, high employee engagement is good for both employees and employers.

A confluence of factors has recently combined to add intense pressure to the workplace. Not surprisingly, Gallup has identified a positive relationship between employee engagement and their well-being. With increased attention to employee wellness, it’s worth noting what managers can do to improve engagement and well-being:

• establish expectations,

• coach continuously, and,

• create accountability

While most managers have a sense of how to set expectations and hold employees accountable, coaching is the tool more commonly missing from a manager’s toolkit. Managers should think of coaching as shorter-term, performance-based conversations.

The three basics for coaching are: 1) frequent conversations, 2) future-oriented conversations, and 3) a developmental focus. Frequent conversations are not intended to micro-manage, but to demonstrate support, ask thoughtful questions, and facilitate employee-owned problem-solving. Managers should approach the coaching conversation with a future focus—less about the negative (what the employee didn’t do or did incorrectly) and more about what the employee will do going forward—strategies, approach, and/or problem-solving. With this coaching mindset, the conversation takes on a developmental focus and provides the employee with a greater sense of career well-being with less stress and burnout.

Many managers will assume a coaching conversation will be both time-consuming and not of value on a frequent basis. Not true. The continuous nature of these conversations enables the manager and employee to build a trusting relationship critical to employee engagement.

Not all coaching conversations will be the same. When an employee begins a new job, managers should get to know the person, their strengths, and career interests, and align expectations. While this conversation might last a few hours yearly, a quick, informal connection once a week offering recognition or feedback focused on the business should only take about five minutes.

Regular coaching conversations of ten to thirty minutes are intended to review successes and barriers, as well as to reset and align priorities. Lastly, semi-annual progress review conversations should center on purpose, goals, metrics, and development.

Mentoring conversations are another tool for managers to support employee engagement. Mentoring takes a longer-term horizon than coaching and is geared toward career development more than performance. Managers might use mentoring—or advice-giving conversations—to transfer knowledge, support career growth, and help retain key talent. These conversations are most beneficial for employees new to an organization or newly promoted. Unlike the frequency of coaching conversations referenced above, the frequency and nature of mentoring conversations should be mutually determined by the mentor and mentee.

So, if you’re business is serious about increasing employee well-being and engagement, coaching and mentoring conversations should be a key element of any effort.

Don Lang is co-founder of Blue Key Partners, a consulting practice helping organizations assess and develop talent. Co-author of Hire the Best: Find, Interview, and Select Top Talent, Don has over 20 years’ experience providing leadership development and coaching programs.

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The Truth About Workers’ Compensation

Steve Heinen

One of my recent social media posts about employees taking personal responsibility for their safety garnered over 12,000 views. Embedded in the post was a poll about employee accountability.

• Seventy-nine percent (79%) of the votes said employers should continuously remind employees that failure to follow safety rules could result in the denial of workers’ compensation benefits.

• Based on the comments, some of the twenty-one percent (21%) were claimant attorneys that feel work comp is a no-fault system and should pay if the employee is injured in the course of and scope of duty. No questions asked. Maybe some employers voted no because they don’t have the type of relationship with their employees to have an honest discussion about workplace injuries. Trust is a big part of an organization’s safety culture and without trust, this type of conversation cannot take place.

I have been involved in over 150,000 Workers’ Compensation claims and here is my perspective: In the event of a serious workplace injury—the loss of an eye, for example—the only party that comes out ahead is the claimant’s attorney. This is not meant to bash claimant attorneys. It is just reality. The claimant’s attorney gets their financial payout and moves on to the next case. Meanwhile, the employer pays higher premiums and may have to deal with the Occupational Safety and Health Administration (OSHA) or Mine Safety and Health Administration (MSHA). However, for the employer, the impact of the claim dissipates over time. No matter what, the employee has to deal with this loss for the rest of their life.

Imagine if the workers’ compensation advertising on television said: “If you have a serious injury at work, workers’ compensation will never make you whole. The best way to be made whole is to think about safety and work safely every day.”

This probably won’t happen, but wouldn’t that be a great message?

This type of messaging is a big part of my new micro-learning initiative to send out short reminders regarding the importance of safety. The initiative has a dual goal. It does have a direct benefit to the employer’s bottom line. Improved safety training and employee buy-in reduce injuries, which lowers costs. Safety also builds trust and accountability. Trust builds when employees feel their best interests are being looked after and this increases accountability. This is why employees take personal accountability for themselves and co-workers as the only proven way to reduce injuries.

I will be expanding on this topic at the Georgia Safety Conference (www. gasafetyconference.com ). If you are attending, please attend my session on Thursday, September 7, 2023, at 8:30 a.m. This is a great conference to increase your Safety IQ®.

Steve Heinen, CWCP, AAI, and partner with Sterling Seacrest Pritchard, has been an active influencer in the insurance industry since 1983 focusing on Workers’ Compensation. He is also the President of Risk Management Inc. where he developed the comP4® process which has helped organizations reduce workers’ compensation associated costs. He is a graduate of the University of Georgia and is active in the Independent Insurance Agents of Georgia. His Work Comp Playbook for Employers has sold over 6,000 copies.

Looking at Return-to-Work Decisions

Shane Mangrum, M.D.

The process of facilitating the return to work for an injured employee can be complicated to navigate as a treating physician. In school, doctors are educated on how to treat injury and illness. Little heed is given in the physician molding process for how to fill out return-to-work forms and the functional issues surrounding the care of injured workers.

From a practice perspective, the terms “restriction,” “limitation,” “capacity,” and “tolerance” are essential to the communication that moves the process of return to work forward. In a colloquial sense, these terms are used loosely or interchangeably. However, in an occupational medicine sense, these terms each have a specific meaning imbued that can encourage clear, consistent communication for all parties with a stake in the process.

The American Medical Association (AMA) Guides to the Evaluation of Work Ability and Return to Work defines these critical terms:

• Restriction = activity advised against because of harm

• Limitations = activity cannot be performed due to a lack of physical or psychological capacity

• Capacity = measurable physical abilities such as strength, flexibility, and endurance

• Tolerance = the ability to tolerate sustained work at a given level. Tolerance is not equivalent to a limitation. Thus, in certain situations a worker “may have the ability to do a certain task (no limitation or restriction), but not the ability to do it comfortably.”

A treating physician must consider these terms carefully when filling out the seemingly ceaseless flow of forms that go along with the return-to-work process for an injured worker. The first question he/she must consider is whether there is a risk of substantial harm with work activity (and not just an increase in symptoms). If there is a risk of substantial harm, the restrictions are indicated.

The second important question in this process is asking if the worker is able to physically do the task in question (again, not considering symptoms, but ability). If no, then the reason can be stated as a limitation. If the answer is yes, then consider issues of tolerance.

The wise George Herbert once said, “Good words are worth much but cost little.” The words we choose as physicians to communicate the roadmap for a return to work are worth much. And, they don’t have to cost much more than a careful moment of consideration.

Shane Mangrum, M.D., is a board-certified physiatrist at Axion Spine & Neurosurgery in Alpharetta in the Atlanta, Georgia metropolitan area. He is double-boarded in physical medicine and rehabilitation, as well as sports medicine. Dr. Mangrum earned his undergraduate degree in organismic and evolutionary biology from Harvard College in Cambridge, Massachusetts. He completed medical school at the University of Utah in Salt Lake City and finished medical training at the Mayo Clinic and the University of Utah. Drawn to the climate and culture of Atlanta, Dr. Mangrum now resides in Milton with his wife and four beautiful children.

“In the sweat of thy brow shalt thou earn thy daily bread: it was not a curse upon mankind, but the balm which reconciled it to existence.” (W. Somerset Maugham)