Code Black and Blue… Broken Bones and Broken Backs

The Daily Life of America’s Healthcare Workers and the Hospitals Failing to Protect Them…

Bernice Friedlun was “circulating” for a heart operation when the surgeon she was working with said he didn’t like the valve replacement pieces she and a second nurse had set out for the procedure.

(Photograph: Courtesy of Bernice Friedlun, April 29, 2017)

An artificial heart valve is a device implanted in the heart of a patient with valvular heart disease. The “circulating” nurse works by collaborating with other members of the team including the anesthesiologist to ensure the proper surgery and safety measures are being performed. The circulating nurse also acts as the patient advocate while the patient is powerless due to the influence of anesthesia.

It was June 30, 2015, and Friedlun had been working as an operating room nurse at Saddleback Memorial Medical Center in Laguna Hills, Calif., for 14 years—5 years “doing hearts,” as she put it. Friedlun went to get a different set of implants, and carried them back past the anesthesia cart. But instead of having its power strip plugged into the ceiling, as it should have been, the cart was connected to a wall socket on a too-short cord.

She was double-checking the pieces as she walked. “I was looking at the sizes, I was checking to make sure they were the right implants while I was walking back around to the other side to put them on the surgical field,” Friedlun, who is now 55, recalled. “I tripped over that cord, and I went down…I went down so hard.” She landed on her right elbow, splitting her humerus [ the long bone that runs from the shoulder to the elbow] into three pieces, the fractures running up and down the length of her arm.

“I remember my arm hit and I saw it hit, and then I looked at it and I thought, it’s not even attached to me. It’s mangled over there,” she said. “I could see it, but it didn’t look like it was attached. I was like, ‘Oh, this is not going to be good.”

As Friedlun lay on the floor of the operating room, gripped with pain, her patient was lying on the table above, chest cracked open and ready for surgery. The patient was on “bypass” [a machine that temporarily replaces the function of the heart and lungs during open heart surgery], which gave the anesthesiologist a bit of time to find a vein in Friedlun’s intact arm and give her an IV full of painkillers before heading off to the ER for a surgery of her own. The patient never learned what happened that day.

According to a report from The Occupational Safety and Health Administration (OSHA), which oversees workplace safety regulations, an employee at Saddleback broke her ankle in January 2013 after an IV pole tipped over and she tripped and fell. Saddleback incurred an initial penalty of $5,000.

Friedlun’s injury, however, was not reported to OSHA. While she was in the emergency room, Friedlun asked a friend to take a picture of the cord and power strip that she tripped on—a hazard numerous people had complained about—but it had already been fixed. “They put in a whole new strip and plugged up in the ceiling. I was like, ‘Oh, okay. There you go.’”

A Dangerous Field

Stories like Bernice Friedlun’s are not uncommon among the 16 million healthcare workers in the country. “Many people do not consider hospital jobs to be high risk, but hospital employees face a different kind of risk than construction workers,” said Edward E. Knauss, IV, a personal injury lawyer at Metzger Wickersham, P.C., in Harrisburg, Pennsylvania.

Not only is the risk different, it is on the whole larger too: The healthcare industry has more work-related injuries than any other sector in the economy, including industries like manufacturing, mining, and construction. On average, there are 34 injuries per 10,000 workers annually, according to data from the OSHA. But for nursing aides, orderlies, and attendants, that rate jumps seven fold—and that’s only counting the incidents that are reported.

The Costs Add Up

A 2013 report by the American Society of Safety Engineers found that injuries to healthcare workers cost $13 billion. Those expenses end up being passed along to patients in the form of higher healthcare costs. As healthcare cost go up, and as there’s an increase in conditions that put employees at risk, like obesity, the problem needs to be addressed now more than ever.

Any injury for a healthcare worker has the potential to be life altering, according to MaryAnn Gruden, community liaison at the Association of Occupation Healthcare Professionals (AOHP). “I’ve seen where nurses tripped on a cord, they have a severe injury, surgery and they can never come back to regular duty. So virtually anything you do in healthcare has the potential to alter your life and lifestyle significantly. So that’s why we need to be concerned about it.”

But that’s no easy feat. Taylor Lincoln, a research director at the corporate and government accountability nonprofit Public Citizen, often asks people why the injury rates are so high, “and why isn’t there more outrage?” Part of the reason, he believes, is because cases like Friedlun’s go unreported. “The workers that get hurt just fade away and nobody really notices them.”

There are three major causes of injuries common in healthcare settings, according Gruden: Lifting patients, which is the leading cause, exposure to bloodborne pathogens, and slip, trips, and falls. There’s also a growing risk of workplace violence, and AOHP is concerned such incidents “will continue to escalate, especially with all of the issues with opioid misuse and drug overdoses that we’re seeing.”

Under Occupational Safety and Health Act of 1970, employers have a duty to provide a safe workplace for their employees. Yet some hospitals are failing to live up to this legislated benchmark. For example, in 2015, OSHA fined Cooper University Hospital in Camden, New Jersey for 15 violations related to exposing employees to needle-stick injuries and bloodborne pathogens. The John L. McClellan Veterans Memorial Hospital in Little Rock received 15 notices of violation for repeatedly exposing its employees to hazards as severe as electrocution and amputation. And the West Haven Medical Center in Connecticut was cited for multiple violations—including 12 repeat offences—that would carry a $480,920 fine in the private sector.

But the vast majority of these injuries are non-fatal, and as such, the broken bones and back injuries suffered by healthcare workers like Friedlun rarely garner much public attention. In many cases, according to Public Citizen’s Lincoln, the workers end up leaving their jobs. “They can’t work anymore because they’ve hurt their back,” he said. “Maybe they do a worker’s comp case, maybe they don’t.”

Workers compensation is a form of insurance providing wage replacement and benefits to employees injured on the job in exchange for their rights to sue the employer for negligence.

Legislation Isn’t Pulling Its Weight

When it comes to patient handling, blood exposure, and falls, there are both laws and technology designed to protect workers. And yet not all protections are created equal: Texas, for example, saw a 29 percent drop in reported musculoskeletal disorders—the type of injuries caused by lifting or moving patients—over the 8 years after the state passed a safe-patient handling law in 2006, according to a 2015 Public Citizen report.

Meanwhile, other states—including California—saw injuries actually increase in the years following passage of similar legislation. In Maryland, there was nearly a 7 percent increase in musculoskeletal injuries between 2006, when the state’s safe patient handling law went into effect, and 2013.

A similar law was passed in 2007 by New Jersey lawmakers with the goal “to minimize unassisted patient handling.” But Danielle Durak didn’t have help from a coworker or mechanical aid two years ago when she tried to reposition an elderly, obese patient at Saint Mary Medical Center in Passaic, New Jersey, who was having trouble with her bed pan. “She was kind of crooked, so I went to go pull the draw sheet that was under her to try to position her out a little bit,” Durak, a registered nurse, recalled. When she pulled the sheet, Durak felt something click in her back. “At that point I was like, ‘Huh, that’s weird,’ but I’m still okay. I didn’t report it because I was okay.”

She finished her shift and went home, and when she woke up the next morning, Durak, who was 27 at the time, couldn’t even get out of bed. The chiropractor who treated her said she should have an MRI—he suspected a torn disc—but she never went. The pain was debilitating enough, Durak was on disability leave for a month and a half. Durak never received worker’s compensation because she never filed a claim. “I didn’t know any better,” she said.

It was 1997 when Jennifer Hecker Bonawitz suffered her own back injury at work, which ultimately ended her career as a certified nursing aid. On a night when the ER was short staffed, a patient came in drunk and suicidal. The nursing staff was told to put him in restraints and move him out into the hall from his room, where he had tried to injure himself, so they could keep a closer eye on him. Bonawitz and a coworker who she described as “a big dude” stood on either side of the patient and went to sit him up. At the count of three, she said, “we both lifted up, but—pop.” Both her back and shoulder were injured.

The movie Titanic came out during the three years Bonawitz, who was 20 at the time, was away from work. “My husband went and bought the bootleg,” she recalled, “because there was no way I could sit in the movie theaters from three hours or two hours, whatever it was.” While worker’s compensation covered some of her lost wages, the lawsuit she brought against her employer didn’t go as Bonawitz had planned. The suit was settled, and her payout “was a joke,” Bonawitz said. She was forced, at a young age, to depend on her husband financially.

Three years after the incident she was still in pain and underwent back surgery. But even still, Bonawitz was forced to change careers in the wake of her injury: Her husband, who was a cop and a first responder on 9/11, died young, and she eventually went back to school, and now works in education.

Do No Harm

Individually, injuries like these cause physical, financial, and emotional harm to workers, but in large, they undermine the quality of care, according to Dr. Tejal K. Gandhi, an associate professor of medicine at Harvard Medical School.

“We want providers to deliver the best, highest quality, safest care to patients, they need to be protected and safe themselves,” Dr. Gandhi said. “That’s why patients and the public should care about this, in terms of wanting the best care for themselves—they need a workforce that’s excited to go to work, having joy and meaning in the work they do, and that are protected physically and psychologically so they can focus on what they should be focusing on, which is taking care of patients.”

The data on injuries show gradual improvement: Following a sharp increase in the late 1980s and early ’90s, hospital injury and illness rates have been gradually declining, down from about 11 cases per 100 full-time employees in 1996 to just over 6 per 100 in 2011, according to Bureau of Labor Statistic data. “But still if you compare to mining, manufacturing, etc., we’re nowhere we need to be,” Dr. Gandhi said. Injury rates in manufacturing dropped below those for hospitals in 1999, and are now approaching the national average for all workers.

While laws and technology can help to reduce the number of injuries, Dr. Gandhi wants to see a larger change in the culture of healthcare too. “We need cultures where people are comfortable talking about risks, talking about errors, they know that if they report something, something will change, people will take it seriously and do something about it.”

Bernice Friedlun was out of work for eight months recovering from her fall. The surgery required knitting the bones back together, which left a jagged L-shaped scar across her shoulder. The time away from work followed a brief personal leave to mourn the suicide of her oldest son.

After Friedlun broke her arm, she filed a workers’ compensation claim, but the $10,000 she received just last month barely covered her expenses for the period she wasn’t working two years ago. Friedlun is divorced, and her other two children are both still living at home with her. She has more to worry about than just herself. “I got a small amount of cash, because I’m, what, 13% disabled they say,” she said. “I can still perform my duties.”

Friedlun was once earning close to $6000 in wages a month (not including her benefit package) as a senior staff –registered nurses was struggling to support her family on a fraction of her income. Her monthly compensation dropped to $3600 a month and did not include medical coverage for her or her children. “I had to pull money out of 401(k)s and out of my pensions and everything else to keep up. I had to start paying Cobra, borrowing from my parents,” she admitted.

After her arm healed, Friedlun had planned on returning to Saddleback, but she wasn’t able to get the same shifts. She was offered part-time hours instead of full-time. “I needed to go back full time. I was refinancing my house, and I was so pissed that they had done that [cut her hours] after I had been out because of the work injury, you know,” she said. “It’s like, not my fault I was gone.”

So, she left, and found another job at Orange Coast Memorial Medical Center, where she is still working in the operating room.

“That was a stressful time. It’s hard to go somewhere else when you have an injury, I just can’t lift heavy things up over my head like I used to,” she said. “The arm I broke was my strong arm in prepping patients. It’s the arm I held with, and I do everything with my right arm. It’s not very strong anymore.” There are certain things that she can’t do anymore, but “I manage,” she said. “I can get through a day with a lot of help from my friends.”

Saddleback Memorial Medical Center, The John L. McClellan Veterans Memorial Hospital, Cooper University Hospital, West Haven Medical Center, and The American Hospital Association were all contacted and questioned about training programs and other safeguards utilized to ensure their employees are protected and equipment is properly operated, but they have yet to respond.

Sources:
Chris Barton, RN: Director Nurse Alliance, SEIU Healthcare 1199NW, 425-917-1199, chrisb@seiu1199nw.org.
Bernice Friedlun, RN: Operating Room/Cardiothoracic Surgical Team, Orange Coast Memorial, Memorial Care Health System, Fountain Valley, California (formerly employed by Saddle Back Memorial Medical Center, Laguna Hills, California, 949.636.2113.
Christine Derr RN: Permanently Disabled (formerly employed by Saint Mary Medical Center, Langhorne PA) 267.566.2518.
Jennifer Dancause RT: Sentara Healthcare, 757.676.5504.
Danielle Durak, RN: Saint Mary Medical Center, Passaic, New Jersey, 201.463.0150.
MaryAnn Gruden, MSN, CRNP, NP-C, COHN-S/CM: AOHP Community Liaison, Association of Occupational Healthcare Professionals in Healthcare, 412-400-6593, magaohp@yahoo.com.
Taylor Lincoln, Research Director: Congress Watch, Public Citizen, Washington, DC (202) 454-5197, tlincoln@citizen.org.
Tejal K. Gandhi, MD, MPH, CPPS: President and CEO of the National Patient Safety Foundation, the NPSF Lucian Leape Institute, and Certification Board for Professionals in Patient Safety. www.npsf.org. Board Certified Internist and Associate Professor of Medicine at Harvard Medical School, 781.559.3104 (home number/landline.
Patricia McTiernan, MS : Assistant Vice President of Communications
National Patient Safety Foundation, www.npsf.org, 617.391.9922 , Pmctiernan@npsf.org.
Louis Henderson: Maintenance Manager, NYP/Columbia Hospital, 646.763.4012, nyp1199Lhenorg@gmail.com.
Keithly Bramble, Jr: Director of Laundry and Patient Transport, NYP/Columbia Hospital, 212.305.6505 kab9081@nyp.org.
Rosa Martinez: Phlebotomist, NYP/Columbia Hospital
George Del-Valle: Perioperative Patient Assistant (PPA), NYP/ Weill-Cornell Hospital, 646.245.5760.
Justine Martinez, RN: Operating Room/ Cardiothoracic Surgical Team, NYP/ Weill-Cornell Hospital, 917.860.4466, jmartinez328@gmail.com.
Jennifer Hecker Bonawitz, (former CNA): Frankford Hospital Healthcare System, 215.990.8370.
Judith Arnetz, PhD, MPH, PT: Professor, Associate Chair for Research, Department of Family Medicine Clinical Center, Michigan State University, 517.884.0436/ 616.234.2823, judy.arnetz@hc.msu.edu.
Bennet J. Battista: organizer, 1199SEIU 212.857.4303/646.221.0969, bennett.batista@1199.org.
Edward E Knauss, IV, Esquire: Partner, Metzger Wickersham, PC, Board certified in civil trial law, Certified specialist in workman’s’ compensation law by the Pennsylvania Bar Association, 717.2388187, www.mwke.com

Government Documents and Websites:
US Department of Labor
Bureau of Labor Statistics
CDC
NIH
Kaiser Family Foundation
Reports Under Taylor Lincoln (Public Citizen)
http://www.citizen.org/health-care-worker-safety-report-series
https://www.citizen.org/sites/default/files/part-four-safe-patient-handling-programs-reduce-injury-report.pdf
https://www.citizen.org/sites/default/files/part-two-safe-patient-technology-policies-report.pdf
https://www.aimseducation.edu/blog/risks-for-healthcare-workers/
https://www.memorialcare.org/saddleback-memorial

Leap frog:
http://www.hospitalsafetygrade.org/h/saddleback-memorial-medical-center-of-laguna-hills
http://healthaffairs.org/blog/2017/03/28/physician-burnout-is-a-public-health-crisis-a-message-to-our-fellow-health-care-ceos/

Reports under Dr. Gandhi (Harvard University):
https://www.osha.gov/dsg/hospitals/documents/1.2_Factbook_508.pdf
https://www.osha.gov/dsg/hospitals/documents/4.1_Overview_508.pdf
http://www.npsf.org
http://kff.org/other/state-indicator/total-health-care-employment/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D
http://www.hospitalsafetygrade.org
http://www.leapfroggroup.org/news-events/fall-2016-leapfrog-hospital-safety-grades-out-now

Hospital Safety: Consumer Reports
http://www.consumerreports.org/cro/2014/03/is-your-hospital-really-as-safe-as-you-think/index.htm
http://www.consumerreports.org/health/hospitals/ratings

OSHA
https://www.osha.gov/SLTC/healthcarefacilities/
www.osha.gov/SLTC/etools/hospital/hazards/sharps/sharps.html
https://www.osha.gov/dsg/hospitals/documents/4.1_Overview_508.pdf
https://www.osha.gov/dsg/hospitals/
http://www.hospitalsafetygrade.org

Healthcare worker Injuries rising
http://www.in.gov/dol/2761.htm

Studies:
Judith Arnetz: (January 2017): Data Driven Approach May Reduce Violence to Hospital Employees,
https://www.sciencedaily.com/releases/2017/01/170112162514.htm