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Brains Not Brawn

The co-morbidities of age and weight compound a case involving a stubborn and injured construction foreman.
By: | March 19, 2015 • 11 min read
Topics: Risk Scenarios
Risk Scenarios are created by Risk & Insurance editors along with leading industry partners. The hypothetical, yet realistic stories, showcase emerging risks that can result in significant losses if not properly addressed.

Disclaimer: The events depicted in this scenario are fictitious. Any similarity to any corporation or person, living or dead, is merely coincidental.

The Injury

The scenario begins with the brief video below:

 

A Grey Area

For five weeks, Mike lives in a grey area populated by denial and tentative healthcare delivery.  Mike reports his injury to his employer and is referred to an occupational medicine specialist. The specialist prescribes Vicodin, a pain killer and Naproxen, an anti-inflammatory.

Mike also discusses light duty alternatives with his employer. Mike tries light duty, taking a stab at acting as a carpenter’s assistant, essentially, cleaning up and doing menial work like sweeping up sawdust and chucking small pieces of wood into the dumpster.

Mike is plagued by pain, and acting against the advice of the occupational medicine specialist, he starts taking two to three Vicodin a day on the job to manage. Buffered by the Vicodin, Mike ignores the verbal agreement he has with his employer and begins to use his shoulder harder.

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At one point, frustrated with the inaccurate work of an underling, Mike picks up a circular saw and starts making cuts to beams and other hefty pieces of wood.

After six weeks, Mike’s pain hasn’t gotten any better and under pressure from Mike’s employer, Mike’s occupational medicine specialist refers him to an orthopedic specialist.

At the orthopedic surgeon’s office, Mike is sitting on the examination table with the doctor standing before him.

The doctor, a much smaller man than Mike, places his right hand on Mike’s left wrist.

“Okay, try to lift your arm,” the doctor says.

Mike tries to lift his arm with the doctor pushing down against him but is struggling.

“You’re very weak in the shoulder,” the doctor says. “I’m afraid you have a substantial rotator cuff tear but we’ll order an MRI just to be sure,” the doctor says.

“What if it’s torn, what then?” Mike says.

“You’re looking at surgery with a minimum of six months off of work,” the doctor says.

Scenario_BrainsNotBrawn“Six months? Why?” says Mike.

“Rehabilitation from rotator cuff surgery isn’t easy. You could have some setbacks. I’m giving you a conservative estimate,” the orthopedic surgeon says.

“Why operate at all?” says Mike.

“You can’t walk around with a rotator cuff tear in your line of work for any period of time,” the doctor says.

“It’s way too risky for a man your age.”

“I’m only 54, Doc,” Mike says gamely.

“At your age, honestly, you’re going to have to be very diligent in rehab to bring this thing back all the way,” the doctor says, tapping Mike lightly on his injured left shoulder.

The MRI confirms what the doctor felt to be true. Mike has a full thickness tear of his rotator cuff.

“You see that?” the doctor says to Mike as they look at the MRI image together.

“Looks like it’s torn all the way through,” Mike says.

“Yes it is,” the surgeon says. “We need to set a date to operate. And as I said during our last visit, you’re going to have to be diligent in rehab to bring this shoulder back successfully.
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A New Reality

As a former high school wrestler and carpenter, Mike is accustomed to injury and injury recovery. It seemed like he recovered from a torn meniscus in his right knee during his wrestling days in a matter of weeks.

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In his twenties, he broke a finger in his right hand in a bar fight in Muscatine, Iowa.

In his thirties, he broke the fifth metatarsal bone in his left foot when he rolled his ankle over a log while dove hunting near Lake Okochobee.

Each time he came back fine. Over the years, Mike developed a quiet confidence that his strong body will never fail him.

But one look at Mike as he sits on his living room couch with his left arm in a sling says that this time might be very different. He’s four weeks post surgery and he’s already gained 20 pounds. Post surgery, his doctor gave him a generous prescription of Oxycontin, 80 pills. Mike still has 50 of those pills, a fact he is keeping from his wife and his doctor.

“Really honey?” his wife says as she stands in the living room doorway watching Mike open another beer as he watches a Florida State football game.

There are three finished beers on the coffee table in front of Mike.  “What?” Mike says as he takes a sip of beer.

“You know what,” his wife says. “You’ve been drinking a lot more beer since you’ve been off work.”

“Not really,” Mike says.

His wife walks closer to Mike and peers into a pizza box.

“You ate that entire pizza?”

“Thin crust,” Mike says by way of a joke.

His wife pauses, not enjoying the joke.

“Are you still taking painkillers? Because you know you shouldn’t be drinking and taking that prescription.”

“Nah, I dumped ‘em in the garbage. I don’t need ‘em anymore.” Mike says.

“Hummmph,” his wife says, not pleased with the whole picture and seeming to doubt Mike’s word.

“What about your physical therapy exercises that you’re supposed to be doing at home?”

“I’m doin’ ‘em,” Mike says.

“When?” his wife asks him.

Mike glares at his wife and she reacts.

“I know what you’re thinking,” she says, crossing her arms.

Scenario_BrainsNotBrawn“You think I’m being a nag. Well I’ve got news for you Mike Manning. Just because I care enough to ask after your health doesn’t make me a nag!”

As soon as she leaves the room, Mike fishes in his pocket and brings out a vial of pills.

With practiced dexterity, Mike uses his slinged left hand to hold the pill bottle while he wrests the top off with his right. Mike pops a pill in his mouth and washes it down with a slug of beer.

Mike had initially taken the painkillers according to the instructions on the bottle. But two months into his recovery, he’s now ingesting twice that amount on a daily basis.

***

Back at his doctor’s office, six weeks post-op, Mike’s shirt is off while the doctor checks his range of motion and his strength.

“Okay, stand up and raise your arm as high as you can,” the doctor says.

Mike gamely raises his arm, but he can’t raise his hand above chest height.

“Keep working hard in therapy,” the doctor says. “How’s your pain?”

Mike gives a pain rating of eight over ten. Excess pain behavior.

“Eh, it still hurts, especially when I’m trying to sleep,” he says.

“Okay, we started you on Oxycontin but I’m going to see if you can get by on Vicodin,” the doctor says.

“Sounds good,” Mike says, avoiding eye contact with the doctor.  Mike still has a renewal on his Oxycontin and he’s happily envisioning doubling up with Oxycontin and Vicodin even before the doctor has put pen to paper to write him a new prescription.

Mike flexes his knee.

“My right knee has started to hurt too,” Mike says. “Don’t know what’s up with that.”

The doctor looks at Mike as Mike flexes the knee.

“It looks like you’ve picked up a considerable amount of weight since you’ve been off Mike. That could be affecting your knee.”

“Yeah, probably so,” Mike said, patting his gut affectionately.

“How’s rehab going?” the doctor says. “You doing the home exercises they’re giving you?”

“Eh…sure,” Mike says.

From the doctor’s expression, he’s not too convinced.

Six months post-injury, Margorie Kessel, a claims supervisor for Mike’s employer’s workers’ compensation carrier, has a look at Mike’s file and does not like what she sees.

“His opioid use is like a runaway train,” Margorie says to herself.

“I’m going to put a nurse on this case.”
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Off the Rails

Nine months post-injury, Mike is at physical therapy, lying on his back while a therapist works on his shoulder.

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The physical therapist is holding Mike’s left arm and trying to gain more range of motion by steadily pushing Mike’s shoulder past where it wants to go.

The therapist is straining, and from the expression on his face, even nine months past injury, Mike is experiencing serious pain in the shoulder.

“Wow,” the therapist says.

“You’re as tight now as you were three months ago.”

“I know,” Mike says without much conviction.

The therapist sheds her sweatshirt.

“You’re giving me a workout,” she says. She picks up Mike’s arm again and resumes work.

Just then, another patient shouts out to Mary.

“Hey Mary, can you come over here? I’m not sure what to do on this exercise ball,” the other patient says.

“Sure, just a sec, Mary says.

“Here Mike,” so some work with this hand weight and I’ll be right back.”

The therapist leaves Mike and he continues on with the hand weight.

The therapist comes back.

“Sorry about that. Where were we?” But instead of picking up Mike’s left arm she picks up his right arm.

“It’s the left arm,” Mike says impatiently.

“Oh, right, sorry about that,” the therapist says.

“Okay, let’s see here,” she says, picking up Mike’s left arm.

She strains again, trying to get some motion out of the stiff joint.

She pauses, tuckered out.

“Are you sure you’re doing those home exercises I’ve been giving you?” she says.  How many times is he doing it? How many times are you doing it?  He can’t remember.

“You’re just not making the progress I’d hoped you would at this point.”

“I’m doin’ ‘em,” Mike says, again, somewhat unconvincingly.

Just then, another patient calls out for help from the overworked therapist.

“Hey Mary, am I doing this leg extension correctly?”

“Um, let me see,” Mary says, as Mike rolls his eyes impatiently.

“Hold on a sec, sorry,” Mary says as she puts Mike’s arm down again.

Mike lies on the table for another couple of minutes as the therapist gets caught up in the other patient’s questions.

Mike looks over to the therapist, working on the other patient.

“That’s it,” he says. “I’m out of here.”

Despite his weight and his gimpy knee, Mike slides off of the table and leaves, limping as he goes.

“Mike! Mike! Where are you going?” Mary says.

“Out! I’m going out of here! I’ve had it!” Mike says.

Three months later, Margorie Kessel is taking another look at Mike’s file.

“So now we’ve got a frozen shoulder.  Probably looking at a six-figure settlement for permanent disability. And he’s still at the drugstore,” she says.

“What the heck happened to this claim?”
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The Session

This scenario was originally presented at the 2014 National Workers’ Compensation and Disability Conference in Las Vegas.

As part of the discussion, panelists discussed key aspects presented in the scenario.

Panelists included Dr. Robert Goldberg, chief medical officer, Healthesystems; and Dr. Kurt Hegmann, Associate Professor, The Rocky Mountain Center for Occupational & Environmental Health. The session was moderated by Tracey Davanport, director, National Managed Care, Argonaut Insurance.

Insights from their discussion are highlighted below:

 

 

 




Dan Reynolds is editor-in-chief of Risk & Insurance. He can be reached at [email protected]

Emerging Risks

Stadium Safety

Soft targets, such as sports stadiums, must increase measures to protect lives and their business.
By: | January 10, 2018 • 8 min read

Acts of violence and terror can break out in even the unlikeliest of places.

Look at the 2013 Boston Marathon, where two bombs went off, killing three and injuring dozens of others in a terrorist attack. Or consider the Orlando Pulse nightclub, where 49 people were killed and 58 wounded. Most recently in Las Vegas, a gunman killed 58 and injured hundreds of others.

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The world is not inherently evil, but these evil acts still find a way into places like churches, schools, concerts and stadiums.

“We didn’t see these kinds of attacks 20 years ago,” said Glenn Chavious, managing director, global sports & recreation practice leader, Industria Risk & Insurance Services.

As a society, we have advanced through technology, he said. Technology’s platform has enabled the message of terror to spread further faster.

“But it’s not just with technology. Our cultures, our personal grievances, have brought people out of their comfort zones.”

Chavious said that people still had these grievances 20 years ago but were less likely to act out. Tech has linked people around the globe to other like-minded individuals, allowing for others to join in on messages of terror.

“The progression of terrorist acts over the last 10 years has very much been central to the emergence of ‘lone wolf’ actors. As was the case in both Manchester and Las Vegas, the ‘lone wolf’ dynamic presents an altogether unique set of challenges for law enforcement and event service professionals,” said John

Glenn Chavious, managing director, global sports & recreation practice leader, Industria Risk & Insurance Services

Tomlinson, senior vice president, head of entertainment, Lockton.

As more violent outbreaks take place in public spaces, risk managers learn from and better understand what attackers want. Each new event enables risk managers to see what works and what can be improved upon to better protect people and places.

But the fact remains that the nature and pattern of attacks are changing.

“Many of these actions are devised in complete obscurity and on impulse, and are carried out by individuals with little to no prior visibility, in terms of behavioral patterns or threat recognition, thus making it virtually impossible to maintain any elements of anticipation by security officials,” said Tomlinson.

With vehicles driving into crowds, active shooters and the random nature of attacks, it’s hard to gauge what might come next, said Warren Harper, global sports & events practice leader, Marsh.

Public spaces like sporting arenas are particularly vulnerable because they are considered ‘soft targets.’ They are areas where people gather in large numbers for recreation. They are welcoming to their patrons and visitors, much like a hospital, and the crowds that attend come in droves.

NFL football stadiums, for example, can hold anywhere from 25,000 to 93,000 people at maximum capacity — and that number doesn’t include workers, players or other behind-the-scenes personnel.

“Attacks are a big risk management issue,” said Chavious. “Insurance is the last resort we want to rely upon. We’d rather be preventing it to avoid such events.”

Preparing for Danger

The second half of 2017 proved a trying few months for the insurance industry, facing hurricanes, earthquakes, wildfires and — unfortunately — multiple mass shootings.

The industry was estimated to take a more than $1 billion hit from the Las Vegas massacre in October 2017. A few years back, the Boston Marathon bombings cost businesses around $333 million each day the city was shut down following the attack. Officials were on a manhunt for the suspects in question, and Boston was on lockdown.

“Many of these actions are devised in complete obscurity and on impulse, and are carried out by individuals with little to no prior visibility.” — John Tomlinson, senior vice president, head of entertainment, Lockton

“Fortunately, we have not had a complete stadium go down,” said Harper. But a mass casualty event at a stadium can lead to the death or injury of athletes, spectators and guests; psychological trauma; potential workers’ comp claims from injured employees; lawsuits; significant reputational damage; property damage and prolonged business interruption losses.

The physical damage, said Harper, might be something risk managers can gauge beforehand, but loss of life is immeasurable.

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The best practice then, said Chavious, is awareness and education.

“A lot of preparedness comes from education. [Stadiums] need a risk management plan.”

First and foremost, Chavious said, stadiums need to perform a security risk assessment. Find out where vulnerable spots are, decide where education can be improved upon and develop other safety measures over time.

Areas outside the stadium are soft targets, said Harper. The parking lot, the ticketing and access areas and even the metro transit areas where guests mingle before and after a game are targeted more often than inside.

Last year, for example, a stadium in Manchester was the target of a bomb, which detonated outside the venue as concert-goers left. In 2015, the Stade de France in Paris was the target of suicide bombers and active shooters, who struck the outside of the stadium while a soccer match was held inside.

Security, therefore, needs to be ready to react both inside and outside the vicinity. Reviewing past events and seeing what works has helped risk mangers improve safety strategies.

“A lot of places are getting into table-top exercises” to make sure their people are really trained, added Harper.

In these exercises, employees from various departments come together to brainstorm and work through a hypothetical terrorist situation.

A facilitator will propose the scenario — an active shooter has been spotted right before the game begins, someone has called in a bomb threat, a driver has fled on foot after driving into a crowd — and the stadium’s staff is asked how they should respond.

“People tend to act on assumptions, which may be wrong, but this is a great setting for them to brainstorm and learn,” said Harper.

Technology and Safety

In addition to education, stadiums are ahead of the game, implementing high-tech security cameras and closed-circuit TV monitoring, requiring game-day audiences to use clear/see-through bags when entering the arena, upping employee training on safety protocols and utilizing vapor wake dogs.

Drones are also adding a protective layer.

John Tomlinson, senior vice president, head of entertainment, Lockton

“Drones are helpful in surveying an area and can alert security to any potential threat,” said Chavious.

“Many stadiums have an area between a city’s metro and the stadium itself. If there’s a disturbance there, and you don’t have a camera in that area, you could use the drone instead of moving physical assets.”

Chavious added that “the overhead view will pick up potential crowd concentration, see if there are too many people in one crowd, or drones can fly overhead and be used to assess situations like a vehicle that’s in a place it shouldn’t be.”

But like with all new technology, drones too have their downsides. There’s the expense of owning, maintaining and operating the drone. Weather conditions can affect how and when a drone is used, so it isn’t a reliable source. And what if that drone gets hacked?

“The evolution of venue security protocols most certainly includes the increased usage of unmanned aerial systems (UAS), including drones, as the scope and territorial vastness provided by UAS, from a monitoring perspective, is much more expansive than ground-based apparatus,” said Tomlinson.

“That said,” he continued, “there have been many documented instances in which the intrusion of unauthorized drones at live events have posed major security concerns and have actually heightened the risk of injury to participants and attendees.”

Still, many experts, including Tomlinson, see drones playing a significant role in safety at stadiums moving forward.

“I believe the utilization of drones will continue to be on the forefront of risk mitigation innovation in the live event space, albeit with some very tight operating controls,” he said.

The SAFETY Act

In response to the terrorist attacks on Sept. 11, 2001, U.S. Homeland Security enacted the Support Anti-Terrorism by Fostering Effective

Warren Harper, global sports & events practice leader, Marsh

Technologies Act (SAFETY Act).

The primary purpose of the SAFETY Act was to encourage potential manufacturers or sellers of anti-terrorism technologies to continue to develop and commercialize these technologies (like video monitoring or drones).

There was a worry that the threat of liability in such an event would deter and prevent sellers from pursing these technologies, which are aimed at saving lives. Instead, the SAFETY Act provides incentive by adding a system of risk and litigation management.

“[The SAFETY Act] is geared toward claims arising out of acts of terrorism,” said Harper.

Bottom line: It’s added financial protection. Businesses both large and small can apply for the SAFETY designation — in fact, many NFL teams push for the designation. So far, four have reached SAFETY certification: Lambeau Field, MetLife Stadium, University of Phoenix Stadium and Gillette Stadium.

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To become certified, reviewers with the SAFETY Act assess stadiums for their compliance with the most up-to-date terrorism products. They look at their built-in emergency response plans, cyber security measures, hiring and training of employees, among other criteria.

The process can take over a year, but once certified, stadiums benefit because liability for an event is lessened. One thing to remember, however, is that the added SAFETY Act protection only holds weight when a catastrophic event is classified as an act of terrorism.

“Generally speaking, I think the SAFETY Act has been instrumental in paving the way for an accelerated development of anti-terrorism products and services,” said Tomlinson.

“The benefit of gaining elements of impunity from third-party liability related matters has served as a catalyst for developers to continue to push the envelope, so to speak, in terms of ideas and innovation.”

So while attackers are changing their methods and trying to stay ahead of safety protocols at stadiums, the SAFETY Act, as well as risk managers and stadium owners, keep stadiums investing in newer, more secure safety measures. &

Autumn Heisler is a staff writer at Risk & Insurance. She can be reached at [email protected]