Mike Flowers is a powerful gatekeeper. He often decides whether to send poultry workers to a doctor when they get hurt on the job or complain of chronic pain.
"I think we do a pretty good job of taking care of these folks," said Flowers, who treats workers at the House of Raeford Farms plant in West Columbia, S.C.
Ernestina Ruiz thinks otherwise.
In 2006, after months of de-boning thousands of chicken breasts each day, her hands and wrists began to hurt. She complained to Flowers at least three times, she said, but each time he gave her pain relievers or a bandage and sent her back to work.
" `You're going to be fine,' " she recalled him saying.
A large lump grew on her left wrist. The pain got so bad, she said, she went to a private doctor and had surgery.
Day after day, poultry workers are cut by knives, burned by chemicals or hurt by repetitive work, according to dozens of injury logs compiled by plants across the South.
Because many workers are illegal immigrants and can't afford private care, their health rests largely with company medical workers.
Those in-house attendants are supposed to help workers heal. Instead, some have prevented workers from receiving medical care that would cost the company money, an Observer investigation has found. And in some instances, the treatments they provide can do more harm than good.
At House of Raeford, some health care workers lack medical credentials. At least two came to their jobs with felony records.
House of Raeford officials said they staff plants with trained personnel who use accepted first-aid practices to handle minor injuries. Workers needing advanced care are referred to doctors, the company said.
"I believe we have provided the care for our employees that's expected," said Gene Shelnutt, the company's human resources director.
In communities near House of Raeford's four largest plants in the Carolinas, more than 30 workers told the Observer that company medical attendants did little to help them when they suffered injuries or complained of pain. More than a dozen, including Ruiz, said those attendants refused their requests to see a doctor.
Ruiz, who began working at the West Columbia plant around 2000, said her hands were hurting after she was moved to the de-boning line, where workers make thousands of cutting and grasping motions each day.
She recalled how sharp pains shot through her hands and wrists each time she grabbed a piece of chicken streaming down the production line.
Medical experts say cysts like the one that grew on Ruiz's wrist often result from repetitive work.
Flowers told the Observer that Ruiz never asked him to see a doctor. And the company had no proof her injury was work-related, he said, noting that the cyst wasn't on her dominant hand.
Ruiz said she used both hands on the de-boning line.
In interviews last year, Ruiz said her hands still ached. She said she could no longer tie her children's shoes, and when she lifted her 1-year-old daughter, she did it with one arm.
"I can't hug her with two hands," she said. "It's not the same."
The cost of care
Companies aren't required to provide on-site medical staff, but many poultry plants have employed them for decades.In an industry known for the pain it inflicts on workers' hands, deciding when to send employees to doctors can have far-reaching effects.
Companies must compensate workers if they are injured on the job and require a doctor's treatment or can't work. Productivity suffers.
When injured workers require treatment beyond first aid, employers also must record those injuries on federal logs; too many injuries can draw scrutiny from workplace safety inspectors.
In this environment, medical gatekeepers can often face a choice: provide workers with the care they need or save the company money.
One House of Raeford worker with carpal tunnel syndrome said a first-aid attendant blamed her hand pain on driving a five-speed car. Another with tendinitis recalled a company nurse saying her pain resulted not from cutting thousands of chickens each day but from a previous case of meningitis.
Doctors say they've heard the stories, too.
Dr. Jorge Garcia, a physician in Newberry, S.C., has treated about 1,000 poultry workers from House of Raeford and two other companies in the past seven years. In about half the cases, he said, the workers' conditions deteriorated because they didn't see a doctor quickly enough.
"They won't send people to a doctor for a week or two or three until the problem gets worse," Garcia said. "I hear that probably 90 percent of the time. By the time they come to me ... they're not getting any better."
`Not the same hand'
Help came too late for former House of Raeford worker Celia Lopez.
Lifting and weighing thousands of turkey breasts each day at a House of Raeford plant near Fayetteville, her hands began to hurt so badly she could barely keep working, she said.
She said she complained to a company first-aid attendant, who gave her pain relievers but didn't send her to a doctor. Months later, in 2006, she saw Harry Cross, a physician assistant on contract with House of Raeford who gave her more pain relievers but recommended no further treatment or testing for her hands, she said.
Lopez went to an independent clinic months later and was diagnosed with carpal tunnel syndrome -- a debilitating hand ailment that can be caused and aggravated by repetitive work. Last year, she had surgeries on both hands to correct the problem.
Dr. Stanley Gilbert, who performed the operations, said that by the time Lopez came to him, her injuries were already serious. Had she come sooner, he said, treatment might have prevented the need for surgery.
"If you don't treat it early enough, you can have permanent damage to the nerve," the Fayetteville doctor told an Observer reporter who accompanied Lopez on a follow-up visit last summer.
It's unclear whether the damage to Lopez's hands is permanent, Gilbert said.
Lopez said she still had trouble lifting dishes and changing her grandson's diapers. Sitting in Gilbert's office, she stared at her hands and lamented the damage: "My left hand -- it's not the same hand."
Asked about Lopez's case last year, House of Raeford said it couldn't comment because she'd hired an attorney. Cross didn't respond to questions about her case.
Lopez, who worked under the name Milagro, was charged last summer with identity theft; police say she assumed another woman's name and Social Security number to get a job.
House of Raeford also declined to comment on the cases of other workers who complained about plant medical care, saying that, without signed releases, it was unable to discuss details of their health or employment. The company said it found "many inaccuracies" in the information workers provided to the Observer but declined to elaborate.
"The allegations made by these former employees do not fairly or accurately represent the policies or management practices of House of Raeford Farms," the company wrote.
Big job, little training
When N.C. OSHA investigated injuries at one House of Raeford plant in 1999 and 2000, it concluded that company policies were inhibiting workers from seeking medical care.The inspectors were trying to determine why many workers at one of the company's plants in Raeford were suffering from injuries commonly caused by repetitive motion.
"We were concerned they weren't going to get the medical treatment, and their symptoms were going to be ignored and just made worse," J.D. Lewis, the state's lead inspector in the case, told the Observer.
In court documents, regulators said a first-aid attendant at the plant had "no special training for the position" and was not licensed as a health care provider or even certified in first aid. Yet the attendant was responsible for evaluating injured workers, treating them and deciding whether to send them to licensed medical providers, the state said.
The state dropped the case in late 2000 after Superior Court Judge Jack Hooks refused to let regulators interview hundreds of workers inside the plant. The judge said inspectors had no authority to investigate further because compliance deadlines for new ergonomics rules had not yet kicked in.
Today, at a neighboring House of Raeford plant, the job of treating and evaluating workers falls to Theodocia Richardson.
Her only formal health care training consists of a daylong CPR class each year, she said.
Still, she said, experience has taught her a lot. Twenty years ago, the company moved her from a job on the production floor to the first-aid station. She said she picked up many of her skills from another company first-aid attendant.
"I don't know where she got hers from, but I got mine from her," Richardson said.
She said she never provides more than basic first aid, but she can call Cross, the physician assistant on contract with the company, if she encounters a situation that's "over my limit."
The company says it follows the plans prescribed by doctors.
"We value our employees and strive to treat them in a fair and respectful manner at all times," the company said in a written response.
`Not right all the time'
At the West Columbia plant, some workers think Mike Flowers is a doctor.
Flowers, the plant's health and safety manager, isn't a doctor -- or even a nurse.
He previously worked as a paramedic -- which requires about a year of training -- and as a deputy coroner. After going to work at the plant in the early 1990s, he said, he also received training on injuries and safety hazards common in poultry factories.
Flowers said he has never represented himself as a doctor, but noted that a receptionist once called him "Dr. Mike" and the name stuck.
"With my experience, I'm able to handle a lot of issues," he said during an interview last year.
Five workers told the Observer that when they complained to Flowers about injuries or persistent pain, he told them they were fine or sent them back to the line after giving them bandages or pain relievers.
Asked whether he ever refused to send workers to a doctor, Flowers said: "I may have, but I say they can go on their own, and if the doctor decides it's work-related, they can bring the bill and I'll file the claim."
But going to a doctor on their own isn't always an option. Some workers can't afford the company's health insurance or treatment from a private doctor. Others are illegal immigrants who fear they'll be fired or deported if they seek medical help.
When employees complain about pain, Flowers asks about their work and medical history and talks with their supervisors before deciding what to do, he said.
"You have to make a decision," he said. "I'm not right all the time, but I'm certainly not wrong all the time."
While carpal tunnel syndrome is common among poultry workers, Flowers' plant didn't record a single case from mid-2003 to early 2007.
Flowers described a test he uses to determine whether workers under his care suffer from carpal tunnel: The thumb, forefinger and middle finger of one hand must all be numb.
Five doctors not associated with House of Raeford criticized that test, telling the Observer it would fail to catch many serious cases of carpal tunnel.
"That's crazy," said Dr. Paul Perlik, a Charlotte hand surgeon. "...If you isolate your diagnosis to that, you could miss a whole lot of stuff."
At House of Raeford and other poultry companies, first-aid workers sometimes provide treatments that may harm workers more than help them.Some attendants, for instance, have dipped workers' aching hands in hot wax or water.
Doctors say the heat momentarily eases pain but can cause inflamed tendons and tissues to swell more.
One worker at House of Raeford's Greenville, S.C., plant said that when he awakes, the fingers of his left hand are often locked into a half fist. The worker, who asked not to be named because he fears losing his job, said he must pull each finger straight. The pain, he said, feels like pulsating needles.
When he visited the company first-aid station, he said, "all they give you is cream, maybe dunk your hand in hot water ... and send you back to the line."
A company nurse refused to send him to a doctor, he said. But he went on his own and was told he was developing carpal tunnel.
"I can put my hand in hot water at home," the worker said. "What do I need a nurse for?"
The nurse at the Greenville plant declined to comment. She is a licensed practical nurse trained in ergonomics, said complex manager Barry Cronic.
"If an employee has even a slight injury or discomfort, (she) takes aggressive medical management to relieve symptoms before a little problem becomes a big problem," Cronic said in a written response to Observer questions.
Trouble with the law
The Observer discovered that two medical workers responsible for the health care of plant employees have criminal records.
Steffeny Harris came to House of Raeford with a record dating to the early 1980s, including felony convictions for forgery and obtaining property under false pretenses. In 1997, she pleaded guilty to misappropriating more than $2,000 from an 84-year-old resident at an assisted living home she ran in Greenwood, S.C.
Soon afterward, she responded to a newspaper ad and was hired as medical director at House of Raeford's Greenville plant. Trained as a certified nursing assistant, Harris said she felt well-equipped to handle the job.
During her time at the plant, from the late 1990s until 2002, Harris said she treated about 50 workers who complained of sore hands and wrists and sent about 15 to a doctor. She referred those workers to physicians only if they complained more than twice, she said.
She said she learned to distinguish between employees who truly needed help and those simply seeking a break from work.
"You can just tell," Harris said.
She said a manager at the plant once summoned her to his office shortly after she was hired and asked why she was sending so many workers to the doctor.
She said she explained that workers were getting hurt.
The manager, she said, told her it was her job to keep workers from going to the doctor.
Harris said she continued to send workers to the doctor if she believed they needed to go.
In a letter to the Observer, Cronic, the complex manager, said: "We absolutely have no recall of such a conversation."
Cross, the physician assistant who has treated House of Raeford workers, also has had trouble with the law.
In 2002, he was sentenced to 27 months in federal prison for submitting false Medicare claims. Among other things, he was accused of submitting bills for examining patients who had already died.
His medical license was reinstated in 2004, after he was released from prison and paid restitution. As of last year he was under contract to provide medical care for House of Raeford workers.
He declined to be interviewed at length but said his criminal record isn't relevant to his work today. "All I'm trying to do is help people on a daily basis," he said.
Shelnutt, House of Raeford's human resources director, said the company didn't know about Cross' criminal record until recently. However, he said, that record "had nothing to do with the treatment of patients.
"I believe people deserve a second chance," he said.
-- Staff writer Karen Garloch and researchers Maria Wygand, Sara Klemmer and Marion Paynter contributed.