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Sunday, August 26, 2012

Whiplash Syndrome. Is it a Medical Emergency?

Whiplash Syndrome.  Is it a Medical Emergency?


This is another post on whiplash syndrome.  Again, I am not writing this stuff for the purpose of spinning something into something more than what it is.

Ask anyone who has ever been rear ended in a car accident, and they will tell you how it felt.  I remember one of my patients a couple years back described to me that it felt like he got his bell rung.  I thought that was a good way of putting it.  He was a huge guy also... almost like an NFL lineman.

Of course, some people, depending on how they are sitting, eg, if their head was against the head rest or turned (6) at the time of the impact, may feel less discomfort than others.  There are also other factors involved like whether your car is moving at the time it was rear ended. (I would actually like to get into that in another post, because what happens here is actually paradoxical to one's thinking.  I will explain in another post.)

So, in a previous post, we have already talked about the fact that more than 50% of  whiplash syndromes fail to resolve. But, what, for example is so terrible about a sprain/strain of the cervical muscles, or even a disc herniation?  What other things occur to a victim of whiplash, or an acceleration/deceleration injury?  I actually did a little research this morning.  www.Pubmed.com is a wonderful source for the latest research abstracts for virtually any scientific subject you may be interested in.  I use it all the time. And you should not take MY word on this topic, when there's tons of literature on this subject.

The following is just the tip of the iceberg when it comes to research on whiplash injury.  Matsui et al, at the Japan Neurological Institute studied whiplash victims and saw that many of these patients experienced various conditions such as chronic fatigue, headache, and vertigo.  Furthermore, his group saw that individuals who underwent treatment for these injuries had reported "good outcome" rates up into the 80% range. (1) Now, what they consider good outcome I don't know.  Good outcome and complete recovery may be two entirely different things.  I actually saw multitudes of studies on vertigo and whiplash.  It seems that vertigo is a common theme after getting rear ended.  Here is a a few articles:  Clinical Symptoms of Equilibrium disorders in patients with whiplash syndrome, Benitez, et al., and Postural  Control Disorders in Initial Phases of Whiplash, Cobo, et al (2,3).  Other authors concluded that 10% of whiplash injuries result in tinnitus, deafness, and vertigo. Trantor, et al.(4).  I can go on for hours finding new articles on this subject. Here is one that caught my attention:  Here is a young lady with minor trauma to the neck, and was diagnosed as having a whiplash.  Patient had normal X-rays, however had paraesthesia of the left arm.  Angiography later revealed the patient had a vertebral artery dissection. (5)

I don't think it is a very long stretch to see that whiplash injuries are very often medical emergencies.  They don't always present as medical emergencies, but the research confirms it.  Doctors should assess these patients objectively, however relating the patient's complaints back to the cause.  And, clinicians should not assume that all whiplash injuries are the same and require the same treatment.  These injuries very often cause permanent deficits of body function and use.  Tinnitus, vertigo, postural changes, and deafness are just a very small handful of the seriousness of whiplash injuries.   If you have been hurt in a whiplash type injury, you can email Dr. Himmel, or you can call Dr. Himmel at 954-659-8600.  I generally answer the phone myself.

Stay tuned.  My next post will be on the physics of the rear end car accident.


1.  2012;52(2):75-80.Cervical neuro-muscular syndrome: discovery of a new disease group caused by abnormalities in the cervical muscles.Matsui T, Ii K, Hojo S, Sano K.

Source

Japan Neurological Institute and Matsui Hospital, Kannonji, Kagawa, Japan. t.matsui@matsui-hp.com
2.   2009 May-Jun;60(3):155-9.[Clinical symptoms of equilibrium disorders in patients with whiplash syndrome]. Uehara Benites MAPérez-Garrigues HMorera Pérez CUnidad de Otoneurología, Servicio de Otorrinolaringología, Hospital La Fe, Valencia, España. michel_u@hotmail.com

3.  2009 May 2;132(16):616-20. Epub 2009 Apr 22.[Postural control disorders in initial phases of whiplash].Pleguezuelos Cobo EGarcía-Alsina JGarcía Almazán COrtiz Fandiño JPérez Mesquida MEGuirao Cano LSamitier Pastor BPerucho Pont CColl Serra EMatarrubias CReveron G.

Source

INVALCOR (Laboratorio de Biomecánica), Barcelona, España; Servicio de Medicina Física y Rehabilitación, Hospital de Mataró, Mataró (Barcelona), España; Universidad Pompeu Fabra, Barcelona, España. 34260ep@comb.es
4.  2009 Feb;16(2):53-5. Epub 2008 Nov 1.A review of the otological aspects of whiplash injury.Tranter RMGraham JRENT Department, Brighton and Sussex University Hospitals NHS Trust, Princess Royal Hospital, Lewes Road, Haywards Heath, West Sussex RH16 4EX, United Kingdom. rtranter@uk-consultants.co.uk


5.  2008 Sep;25(9):609-10. Neck pain and minor trauma: normal radiographs do not always exclude serious pathology. Ribbons TBell SAccident and Emergency Department, Queen Alexandra Hospital, Southwick Hill Road, Cosham, Portsmouth, UK. tamsinribbons@doctors.org.uk

6.  2008 Jul 1;33(15):1643-9.  Head-turned postures increase the risk of cervical facet capsule injury during whiplashSiegmund GPDavis MBQuinn KPHines EMyers BSEjima SOno KKamiji KYasuki TWinkelstein BA.

Source

MEA Forensic Engineers & Scientists, Richmond, BC, Canada. gunter.siegmund@meaforensic.com

Shhhh! THE CHANGES TO YOUR FLORIDA PIP NO-FAULT BENEFITS ARE A SECRET! YOU ARE NOT SUPPOSED TO KNOW!

Shhhh!  THE CHANGES TO YOUR FLORIDA PIP NO-FAULT BENEFITS ARE A SECRET!  

YOU ARE NOT SUPPOSED TO KNOW!


Here's one for you. Last week I had a patient come in to my office for a back problem, not car accident pain related.   He is an AllState Insurance salesman and supervisor at a local Allstate office.  We made the usual small talk.  I like to get to know a little about my patients; its easy to do when you are in a small room for 45 minutes to an hour.  But anyway...

So, I asked him what he thought of the changes to the No-Fault law. You know what he said? He said, "what changes?"

You see, even the people that sell insurance, who are supposed to be knowledgeable and up to date with what product they are selling, are being kept in the dark. This is exactly how the insurance companies want it. And, if I'm not mistaken, it was written into the new law that consumers are NOT REQUIRED to be advised of these changes. Can you believe this? So, the insurance companies push to eliminate 75% of your coverage--a coverage that is mandated by the state in order for you to drive, and they don't even send a memo or a letter to the SALES PEOPLE advising them of any upcoming changes.  As of today, we are only a 130 something days away from the new year.  How is it that this AllState Agent and supervisor had no idea about this?

So, here we go again.  The consumer does not know about these changes because even the insurance company agents are kept in the dark and furthermore, the companies are not required to let their policy holders know in advance of the changes.   Why let the cat out of the bag?  Why let people know about this now?  After all, there will always be accidents where people are injured.  By not talking about it, the insurance companies stand to save a BOAT LOAD of money, if people simply wait one day too long to get treated.  The information "probably" will be written into the new policies that renew, but even still, most people are not going to bother to read it.   And its not going to be on the front page of the policy.  The Dec page will still look the same;  it will say PIP NO FAULT--------$10,000.  Any reference to the changes or 75% decrease or the 14 days, will be written in the smaller print.   

Yet another unfair process.  I mean, credit card companies are required to send you letters advising you of interest changes or new rules, etc.  Investment funds are constantly updating their clients about any changes they may affect the investments.  But, auto insurance companies here in FL are not required to let you know about these very important changes.   I mean, how is one supposed to be prudent after an accident if they are not made aware of their responsibilities?   If you make one mistake like waiting 15 days to see a doctor, you have just given up all your PIP insurance benefits.  Yes, these are the benefits you paid for out of hard work.  These are the benefits that are REQUIRED for you to buy in order to register your car for the road.  This is a state law now.

My patient did have an interesting take on it. He said that the reason why he doesn't know about this, is because the AllState insurance company wants to make it look like it wasn't AllState who had anything to do with the changes. They will simply blame it on Florida.  Its like, "Hey, don't look at us, we had nothing to do with it. This is state law. Go take it up with your representative." 

He's probably at least partially right about this .  Sometimes I wonder if we live in the United States.

Alan Himmel, DC.
954-659-8600

Wednesday, August 22, 2012

Soft Tissue Injuries: Whiplash Recovery is Estimated to be at 50% or less.


Soft Tissue Injuries.  Whiplash Recovery is Estimated to be at 50% or less.

Alan Himmel, DC.,PA.

I wanted to talk for just a little bit about soft tissue injuries.

Most people think that unless you are a person who has suffered from a soft tissue injury (STI), that these types of injuries are no big deal. Well, nothing can be further from the truth, and I'll tell you why:

The body is an amazing thing. If you simply step out of the way, and let the body do what it does, it heals itself pretty well. For example, of you cut your finger, bite your lip, or even sustain a burn, the skin goes through a process of healing where it sends some specific blood cells to the scene of the injury and gets the job done. Even bone heals up pretty nice as long as the fracture doesn't involve a joint or articulation between two bones.

But, an injury to muscle, ligament, or tendon, or nerve is not the same as a small scratch or a bruise.  I mean, the cellular and chemical process by which the body begins the healing process is the same, but since the injury affects muscles, ligaments, tendons, and nerves, the injury will generally affect the ability of the person to move their body and function.



Anyone who has ever sprained an ankle or a knee knows that these injuries, despite the body's best attempt at healing, take a very long time and also cause permanent deficits in function. Injured tendons and ligaments and other soft tissue usually involves fine tears of the fibers. There are of course different grades of these types of injuries which range from a few small torn micro-fibers, to a severe tear or rupture which should be surgically repaired to reconnect. Every sprain, whether it happens to a person's neck as in a whiplash, or ankle while playing basketball, involve torn fibers. These pulled and torn  fibers are the cause of pain, inflammation and loss of range of motion which is typical of these injuries. So, expect a loss of range of motion of your neck if you have sustained a whiplash.


One of the things that I see in my office, and one that repeatedly comes up on MRI's is straightening of the cervical spine.  It is often seen after a whiplash trauma and is often considered by some doctors to be a normal variant, which is unlikely to be of any concern.  And, I'm sure many of the practitioners out there who are reading this are thinking, " big deal", everyone has this.  In fact many orthopedists are not concerned by this at all.  But, I studied this.  It is my job to tell it like it is, even if it goes against the normal thinking many of my colleagues.  I will tell you why this is something that clinicians should be aware of and in fact, should be concerned about.



You see, the curve, or lordosis, in the cervical spine is not there by accident.  In fact, its there actually to help buffer the spine and protect the spinal cord from shock due to the possibility of axial forces or downward compression from the head due to trauma.  Just think, if you had a spine which was as straight as a pencil, every time you even took a step, the joints of the spine would have to deal with the compressive forces and the possibility of injury or even fracture of a bone.  As an experiment, take that pencil that's on your desk, hold it in your hand, and now, jam it directly into a book or something on your desk.  Now, imagine doing the same thing with a pencil that has a slight c-shape curve to it.  I bet that you could feel the impact of that straight pencil going into the book, but the curved one is able to take or absorb some of the energy of the force.  You will feel that the curved one sent less of a shock up through your hand.   Think about that for a moment.

The next thing you have to be aware of is that the spine has supportive structures like the Anterior Longitudinal Ligaments (ALL) and Ligamentum Flavum (LF) which are often damaged from a whiplash injury. (3)  These ligaments connect from bone to bone, and in this case, your cervical vertebrae, which helps to keep these bones together and keep the normal cervical lordotic curve. An interesting study which confirms injures to these ligaments due to whiplash, was recently completed by Fice and Cronin in Ontario,and in fact, thet studied the minimal G-forces required to cause these ligamentous disruptions. (4)   Thus it is clear that these important ligaments in the cervical spine are there for supportive reasons.  When we see a spine of a patient post whiplash, very often we see the straightening which may be due to a disruption of these important pieces of connective tissue. (5)  Just as you wouldn't ignore an ankle sprain which involves  disruption of ligaments, you should also never ignore disrupted ligaments in the cervical spine.  I think we can all agree that this is a much more critical part of the human anatomy.

So, does this sound like something you want to ignore? These types of injuries without a doubt require some sort of rehab. If left alone, you can expect a permanent loss of function and/or pain. Up to 50% of individuals who suffer a whiplash will fail to recover.(1)  Other studies have the rate of recovery even worse. (2) The patient should be slowly rehabilitated using various methods. This, in my opinion is an emergency. It might not be a life or death emergency, but this injury could cause permanent loss of function of a body part, and sometimes a noticeable straightening and deformity.  It needs to be treated and treated right away in order to limit the amount of loss.

If you have a whiplash type injury, find your local chiropractor.  We are trained to help people hurt like this.  If you are in South Florida, you can call me to schedule an appointment.

I have two websites because I draw patients from both Miramar and Pembroke Pines. Check out my websites: www.MiramarChiropractor.com and www.PembrokePines-Chiropractor.com

Refrences:

1.  2011 Dec 1;36(25 Suppl):S330-4.

Prognosis after whiplash injury: where to from here? Discussion paper 4.

Source

Centre of National Research on Disability and Rehabilitation Medicine, The University of Queensland, Brisbane, Queensland, Australia. m.sterling@uq.edu.au
2.  2011 Jan;42(1):25-32.

Identifying predictors of early non-recovery in a compensation setting: The Whiplash Outcome Study.

Source

Rehabilitation Studies Unit, Sydney Medical School, University of Sydney, Sydney, NSW 2006, Australia. pcas0573@uni.sydney.edu.au, petrina@harvard.co.nz
3.   2012 Aug 30. [Epub ahead of print]

The effects of ligamentous injury in the human lower cervical spine.

Source

Orthopaedic Bioengineering Research Laboratory, Department of Mechanical Engineering, Colorado State University, Fort Collins, CO 80523, USA.
4.   2012 Apr 5;45(6):1098-102. Epub 2012 Jan 28.

Investigation of whiplash injuries in the upper cervical spine using a detailed neck model.

Source

Department of Mechanical Engineering, University of Waterloo, Waterloo, Ontario, Canada N2L 3G1. jfice@uwaterloo.ca
5.   2010 Jan 14;130(1):29-32.

[Anatomy of the cervical spine].

[Article in Norwegian]

Source

Institutt for medisinske basalfag, Avdeling for anatomi, Universitetet i Oslo, Postboks 1105, Blindern 0317 Oslo, Norway. per.holck@medisin.uio.no

Saturday, August 11, 2012

COUNTDOWN TO THE CHANGE IN THE FLORIDA PIP NO FAULT LAW

See this timer below? This is The amount of time you have left as a Resident and Florida Driver under the old rules. On January 1, 2013, your Florida Car Insurance will only pay for your accident injuries if you go to a doctor within the first 14 days. Also, the coverage for injuries will be reduced to only $2500 from $10,000 for non-emergency claims . Finally, the cost of your insurance will likely not change. This is all thanks to Rick Scott and many of your elected officials in Florida.

Tuesday, August 7, 2012

I had a Car Accident. Do I Call a Doctor or Call a Lawyer First?


I had a Car Accident.  Do I Call a Doctor or Call a Lawyer First?
Lets shift gears a bit here and talk about something that bugs me quite often.


Many patients of mine come to my office for injuries including whiplash treatment after they have been involved in a car accident, but all too often the first phone call they make is to an attorney.  I have seen this hundreds of times over the last sixteen years of practice as your Chiropractor and I immediately stop and explain to the patient that in most cases this is not a very good way to proceed.  Now, if you are an attorney reading this, you are not happy that I am saying this.  You are not happy that I am telling the truth, in what I am about to divulge.  The reason being, is that if you are a lawyer, you want to maintain control of the whole situation, which includes of course, where the client goes for treatment.  However, even though I type these words, it is not going to change the fact that many if not most accident victims will do just that--contact an attorney first.  

It turns out, for many people involved in an accident and are injured, the first thought after the loud crash and the cars have come to rest is, "I'm gonna sue that guy."   This is the wrong way of thinking, as you can imagine.  What is important is that only under certain conditions is it wise to contact a lawyer before a doctor.  You see, the insurance claim representatives are trained to recognize a claim that is based on real injuries and back pain or whiplash versus a claim that is based on the foundation of, "Pay Me."  If you have a car accident and the first thing you do is hire a lawyer, and the lawyer "sends" you to one of "his" doctors, the insurance representative who holds the checkbook is going to pick your claim out of the stack and is likely to scrutinize the treatments and question the claimants motivation.

Now, although you may have a legal right to fight for compensation if you are a victim with injuries due to someone else's doing, in most cases you are not actually suing anyone at all, rather you are putting an insurance company on notice and they should be prepared in the future for a monetary demand.  Well, insurance companies have departments set aside to handle these phone calls and demands.  It's called a claims department.  In fact, the insurance company creates teams of trained specialists that sit behind desks, and answer these calls and literally process these claims all day, to pay out to accident victims.  Actually, it is very rare that an insurance company is actually sued to pay these bodily injury claims.  They simply look at the facts, damages, and injuries of the claim, and make a determination as to what they think the claim is worth.  The next thing that happens is that your lawyer tries to negotiate that amount as high as possible.  It's like buying a car, when you go back and forth with the salesman until the price is agreeable. 

I explain this to patients all the time because sometimes it even makes me question my patient's motives if they contacted a lawyer before receiving treatent.  I have an obligation to release patients from care if I feel they are not as hurt physically as they want you to believe. There is a word for this.  The word is "malingering."   Contact your doctor first, not a lawyer. 
My Chiropractic Clinic is in the Miramar/Pembroke Pines area of South Florida.  Call me for an appointment. Dr. Alan Himmel 954-659-8600

Monday, August 6, 2012

Florida No fault Emergency Medical Condition

What about the So-Called Emergency Medical Condition (EMC) requirement?

Dr. Alan Himmel

Florida No-Fault PIP law, now states that only emergency medical conditions have $10k in medical benefits and that the EMC must be diagnosed by a MD, DO, ANRP, or PA.


This could be defined as acute pain, but it seems that in order for the $10k in coverage to be applied, it must be the opinion of one of the above medical professionals, that the car accident injury, without immediate attention, will result in any of the following: 


(a) Serious Jeopardy to the patient health.

(b) Serious impairment to bodily functions.
(c) Serious dysfunction of any bodily organ or part.

Pain is the body's way of saying that there is something wrong. Its the body's alarm system. However, it doesnt always lead to any of the above scenarios listed in a, b, and c. Or does it? One could make the argument that pain due to an accident which caused, say, a herniated vertebral disc, could result in neurological deficits and muscle weakness and atrophy. The question is whether the insurance companies will regard this as, (c) serious dysfunction of a body part. If a person can no longer walk they way he or she did, I would certainly think this would be serious.



This sure leaves a lot of power to an insurance company adjuster, to decide how to handle the claim, and most people expect the insurance carriers to fight every EMC claim tooth and nail.


Keep your eyes on this blog.  I will be posting articles regarding Emergency Medical Conditions.  

Sunday, August 5, 2012

Florida No Fault 14 Day Treatment Rule.

SUPPOSE YOU HAVE A CAR ACCIDENT ON JAN 1, 2013 OR LATER...

Dr. Alan Himmel

Is anyone aware of another little change to the Florida No-Fault PIP law that goes into effect on Jan 1, 2013?  Of course not, so I am here to inform you of another very important fact that you should know if you are an insured Florida resident.

Let me set the scene: You are either the victim of or an at fault driver involved in an auto accident which occurs on, lets say Jan 1, 2013 or thereafter.  You are driving, and all of a sudden, you collide with another car which is not stopping.  The accident causes car causing damage, and also caused some neck pain and headache.  You go home that day and you take some Ibuprofen and ice it, and your neck and headache feel a little better.  You decide that the pain is not so bad, and  you figure that the neck stiffness that is setting in, is no big deal.  After all, you have had a stiff neck in the past, and it always goes away within a week or so.  So, you just decide to rest it, ice it, and take over the counter pain killers. It actually begins to feel better after about a week, and at this point you figure it will continue improving.  You are busy at work and with the family.  You don't have time to waste going to doctors and getting xrays, because you think that you will be OK, and its not that important anyway.  But it starts to get to a point that the neck pain and stiffness are not improving anymore and your wife is telling you to go get checked out.  So, you make an appointment at your doctors office.  Today is Friday and your doctor cannot see you until Monday;  so take it.

Well, little did you know, that Monday is exactly 15 days after your car accident.  You go to get checked out, and your doctor is worried and decides to order an MRI to rule out serious problems. He also writes you a prescription and that same night, you get the MRI done.  The report comes back in a few days and there are two cervical disc herniations.  Well, your doctor at this point is thinking Orthopedics, Physical Therapy or Chiropractic care, because he knows that these things left untreated can very often get worse to the point that there is radiating pain, numbness, and tingling down your arms.  He tells you that sometimes these things require surgery.  Now you are worried.



But wait!  At least you were responsible enough to pay your auto insurance, which is mandatory in Florida.  You have always been a responsible person and actually you have been paying for years and never missed a payment and never even filed a claim.  By the way, just to let you all know, PIP insurance is primary in Florida, meaning that if you decide to use your health insurance, your health insurance company will deny your claim because your injury is auto accident related.  But, not to worry, you have GEICO.  Or was it Allstate?  Or Progressive....   Hmmm.  It doesn't matter anyway, which insurance company you have.

Do you know why?

Because your Governer, Mr. Rick Scott, created a law that states that you must initiate treatment within the first 14 days and you waited 15 days.  You are now completely out of luck.  You paid for your coverage and now your wonderful elected officials created a new way for your insurance company to deny your claim.   No coverage for you.  Your insurance company gets off the hook and they get to keep the money you paid them.  They don't have to pay your doctor bills.  And guess what?  Its a state law!

Do Not Wait.  If you have been involved in a car accident in Miramar or a car accident in Pembroke Pines FL, You should get treatment immediately.  You can call me personally, Dr. Alan Himmel.  I answer the phone myself.  954-659-8600 or 305-979-5549

You can also check out my Website, www.MiramarChiropractor.com



Friday, August 3, 2012

The Florida No fault PIP Law; A Brief Overview.

To start, let me summarize the New No-Fault insurance changes that are taking place in Florida for 2013.

Dr. Alan Himmel

A little history:  The Florida No fault law was enacted in the early 1970's to ensure drivers in the state of FL were protected if they were injured in a car accident.  It covers medical expenses as well as lost wages and it has a death benefit.  "No Fault" means that you are covered no matter who is at fault.  This is what the term no fault essentially means.  Whether you are a passenger, a driver or a pedestrian;  if you are injured in, near, or around a car, you are most likely covered under the Florida No Fault Law.  It was designed with both the Florida citizen in mind, and also for the purpose of reducing law suits.

The coverages have changed over the last four decades with little things, and a few years ago, the no fault law "sun-setted" (was removed completely), but then was quickly reenacted.  There has been $10k in benefits that would cover an individual for virtually any injury resulting from a car accident, including the most obvious, whiplash injury or disc herniation.  And, it covers all the occupants in a car if necessary.

Over the years, the insurance lobby has been fighting to get rid of this important insurance that everyone driving a car is required to have.  It turns out, by the way, that $10k in insurance doesn't go very far at all, especially since health care is so expensive now and the $10k dollar amount was decided upon decades ago in the 70's, when everything was much cheaper.  Most people are unaware that if you take a ride to the hospital in an ambulance, you are there for a few hours, and you are given one or two diagnostic tests like an MRI or CAT scan, your bills could easily top the $10,000 limit of coverage.

I have had many patients over the years who have come to my office a day after leaving the hospital, with absolutely no coverage left for any follow up care or physical therapy.  In other words, the hospital completely exhausted the patient's PIP policy, left them without any coverage, AND sent them out with instructions to follow up with their doctor.

Anyway, this year in 2012, your wonderful governor and the rest of the crew decided to make big changes to your insurance benefit.  Great!  So they increased the coverages to reflect the economy and average cost of health care, right?

No,  well I think you know where I am going with this.  The amount was not increased accordingly like it should have been.  In fact, your PIP insurance has essentially been cut by 75% down to $2500 for what they call non emergency injuries, (which by the way account for the majority of accident injuries).

 The law goes into effect on Jan 1, 2013.

What does this mean?  It means that if you go to the hospital after an accident, and the doctor sees your injury as a soft tissue complaint like a disc herniation or rotator cuff tear, for example,  you will leave the hospital with little if any coverage left for follow up care.  AND, your insurance premium will likely not change by much at all.  In other words, you will still be paying the same amount for your car insurance but now you will have only 25% of the coverage that you had before.  How anti-consumer is that?  You can all thank your governor, Rick Scott.  It was essentially his bill and one of his "greatest accomplishments" of his career as governor so far.