Occupational Medicine: Occupational Medicine: Whazzat?Whazzat?

The Rodney Dangerfields of The Rodney Dangerfields of medicinemedicine

William G. Buchta, MD, MPHWilliam G. Buchta, MD, MPHFebruary 25, 2009February 25, 2009

Key PointsKey Points

►Population focus forPopulation focus for IndividualsIndividuals GroupsGroups

►Hazard/risk analysisHazard/risk analysis►Special ethics/rolesSpecial ethics/roles►Causation Causation ►The perksThe perks

Population FocusPopulation Focus

►Public health for working populationPublic health for working population Healthier Healthier Narrower age rangeNarrower age range Special skillsSpecial skills Special physical attributesSpecial physical attributes Typically not ones to see doctorsTypically not ones to see doctors

►Seeing the patient in context of workSeeing the patient in context of work►Remembering the denominatorRemembering the denominator

Seeing the patient in context of Seeing the patient in context of workwork

►Post-offer pre-placement evaluationPost-offer pre-placement evaluation Job descriptionJob description Job-appropriate medical evaluationJob-appropriate medical evaluation Risk assessmentRisk assessment CommunicationCommunication

► Injury/illness evaluation and treatmentInjury/illness evaluation and treatment Work-relatedWork-related Non-work-relatedNon-work-related

Non-work-related Non-work-related illness/injuryillness/injury

►Acute infection: MRSA, URI, AGEAcute infection: MRSA, URI, AGE►Sports injurySports injury►Chronic diseaseChronic disease

HepatitisHepatitis DiabetesDiabetes Ischemic heart diseaseIschemic heart disease Depression/anxietyDepression/anxiety ArthritisArthritis

Work-related injury/illnessWork-related injury/illness

► Low back painLow back pain► LacerationsLacerations► Eye injuriesEye injuries► DermatitisDermatitis► Lung diseaseLung disease► HepatitisHepatitis► CancerCancer► Death by crush, fall, explosion, asphyxia, Death by crush, fall, explosion, asphyxia,

gunshot, freezing, burning, etc.gunshot, freezing, burning, etc.

ExamplesExamples

► Lung disease: Lung disease: pneumoconiosespneumoconioses, asthma, asthma► Cancer: bladder, lung, skinCancer: bladder, lung, skin► CV toxicity: CO, methylene chlorideCV toxicity: CO, methylene chloride► Reproductive: DBCP, methotrexateReproductive: DBCP, methotrexate► Nervous system: Hexane, manganeseNervous system: Hexane, manganese► Dermatitis: metal-working fluid, Dermatitis: metal-working fluid, cementcement► Psychological: burn-out, depression, PTSDPsychological: burn-out, depression, PTSD► MSK: tendonitis, epicondylitis, 1MSK: tendonitis, epicondylitis, 1stst MCP DJD, MCP DJD,

NOT carpal tunnel syndrome NOT carpal tunnel syndrome

Worker CompensationWorker Compensation

► One of most misunderstood medical plansOne of most misunderstood medical plans► Different in each stateDifferent in each state► 100% medical coverage100% medical coverage► 2/3 pay for time off2/3 pay for time off► Monetary and rehab benefits for permanent Monetary and rehab benefits for permanent

impairment (PPD at MMI)impairment (PPD at MMI) Per statute 5223 in MinnesotaPer statute 5223 in Minnesota

► Administrative law; no option to sue employerAdministrative law; no option to sue employer► Pays 85% or better of U & C chargesPays 85% or better of U & C charges► Our contribution to maintaining a healthy Our contribution to maintaining a healthy

workforceworkforce

Social Security DisabilitySocial Security Disability

►Covers workers disabled from work for Covers workers disabled from work for any medical reasonany medical reason

►Off work for 1 year or moreOff work for 1 year or more►Requires application, medical Requires application, medical

verificationverification►Reviewed every 3 to 7 yearsReviewed every 3 to 7 years►Subsistence paymentsSubsistence payments►May include MedicareMay include Medicare►NOT heaven on earthNOT heaven on earth

Occupational HazardsOccupational Hazards

►Mechanical: lift, push, pull, reach, walkMechanical: lift, push, pull, reach, walk►Chemical: acids, alkalai, solventsChemical: acids, alkalai, solvents►Physical: heat, cold, vibration, noise, lightPhysical: heat, cold, vibration, noise, light►Biological: bacteria, fungi, bees, poison ivyBiological: bacteria, fungi, bees, poison ivy►Psychological: pace, complexity, long shifts Psychological: pace, complexity, long shifts ►Social: harassment, discrimination, Social: harassment, discrimination,

inequityinequity

And now for some graphic And now for some graphic examples….examples….

►The power of gravity The power of gravity http://www.youtube.com/watch?v=0189LO5FyqMhttp://www.youtube.com/watch?v=0189LO5FyqM

►The hazardous ladder The hazardous ladder http://www.youtube.com/watch?v=xbVaXHUu_qchttp://www.youtube.com/watch?v=xbVaXHUu_qc

►Crane gone crazy Crane gone crazy http://www.youtube.com/watch?v=5WQPfbEFprkhttp://www.youtube.com/watch?v=5WQPfbEFprk

►Steel mills Steel mills http://www.youtube.com/watch?http://www.youtube.com/watch?v=_hlfqggGOZwv=_hlfqggGOZw

More examples …More examples …►Aircraft carrier Aircraft carrier

http://www.youtube.com/watch?v=4ChD8TMI3p8http://www.youtube.com/watch?v=4ChD8TMI3p8

►Salt mines Salt mines http://www.youtube.com/watch?http://www.youtube.com/watch?v=Bi9bJhRZtKAv=Bi9bJhRZtKA

►Tanneries Tanneries http://www.youtube.com/watch?http://www.youtube.com/watch?v=2AS6pAWR9n4v=2AS6pAWR9n4

Even more examples …Even more examples …

►Office stress. So, this is light duty?Office stress. So, this is light duty? http://www.youtube.com/watch?v=s5qHLPbvI

5I http://www.youtube.com/watch?v=sTJcBHA9b

hM

►Sex discrimination at workSex discrimination at work http://www.youtube.com/watch?v=goOHAhH

EU_I http://www.youtube.com/watch?v=WhswqZh

2Rc4 http://www.youtube.com/watch?http://www.youtube.com/watch?

v=R9ZfIFQQvzcv=R9ZfIFQQvzc

Special Ethics Special Ethics

►Serve the employee or employer?Serve the employee or employer?►Medical evaluation without Medical evaluation without

doctor/patient relationshipdoctor/patient relationship►Communication of medical status to Communication of medical status to

HR (FMLA, ADAAA, job fitness)HR (FMLA, ADAAA, job fitness) Safety staffSafety staff InsurerInsurer Supervisor (HIPAA)Supervisor (HIPAA)

Forensic/Hazard EvaluationsForensic/Hazard Evaluations

►Safety-sensitive jobsSafety-sensitive jobs Truck driversTruck drivers Pilots/Air traffic controllersPilots/Air traffic controllers Nuclear power plant workersNuclear power plant workers

►Particular job categoriesParticular job categories Lead workers (blood lead)Lead workers (blood lead) Asbestos workers (CXR)Asbestos workers (CXR) Oncology nurses/pharmacists (Surveys)Oncology nurses/pharmacists (Surveys) Radiologists (badges)Radiologists (badges)

Causation:Causation:Sherlock Holmes roleSherlock Holmes role

►HistoricalHistorical 1500s, Paracelsus, “Dose is the poison.”1500s, Paracelsus, “Dose is the poison.” 1600s, Ramazzini, 1600s, Ramazzini, Diseases of WorkersDiseases of Workers 1700s, Percival Potts, scrotal cancer in 1700s, Percival Potts, scrotal cancer in

chimney sweepschimney sweeps 1900s1900s

►Alice Hamilton, Alice Hamilton, Exploring the Dangerous Exploring the Dangerous TradesTrades

►Harriet Hardy, berylliosis registry in industryHarriet Hardy, berylliosis registry in industry►Irving Selikoff, asbestos-related diseases Irving Selikoff, asbestos-related diseases

among industrial workers among industrial workers

Austin Bradford HillAustin Bradford Hillstatisticianstatistician

1954, 1954, British Doctor StudyBritish Doctor Studyhttp://www.youtube.com/watch?v=nwVxuu6Ugmghttp://www.youtube.com/watch?v=nwVxuu6Ugmg

1.1. Strength of associationStrength of association2.2. ConsistencyConsistency3.3. SpecificitySpecificity4.4. TemporalityTemporality5.5. Biological gradient (dose/response)Biological gradient (dose/response)6.6. PlausibilityPlausibility7.7. CoherenceCoherence8.8. ExperimentExperiment9.9. AnalogyAnalogy

NOEL vs. HormesisNOEL vs. Hormesis

Lungcancer

Radiation from Radon

Uranium miners

Recent DiscoveriesRecent Discoveries

►A mystery in MissouriA mystery in Missouri►The other white meat diseaseThe other white meat disease

A mystery in MissouriA mystery in Missouri

►2000: lawyer approaches a doctor in 2000: lawyer approaches a doctor in Kansas cityKansas city 8 cases of “strange lung problems”8 cases of “strange lung problems” All worked at same popcorn plantAll worked at same popcorn plant

Common CharacteristicsCommon Characteristics

►Symptoms: dyspnea on exertion, coughSymptoms: dyspnea on exertion, cough►Exam: decreased sounds, basilar ralesExam: decreased sounds, basilar rales►Tests:Tests:

CXR: lung expansionCXR: lung expansion PFTs: non-reversible obstructionPFTs: non-reversible obstruction Diffusing capacity: normalDiffusing capacity: normal CT: air trapping, bronchiectasisCT: air trapping, bronchiectasis Lung biopsy: bronchiolar fibrosis/narrowingLung biopsy: bronchiolar fibrosis/narrowing

Bronchiolitis obliteransBronchiolitis obliterans

Popcorn PlantPopcorn Plant

► ProcessProcess Mix salt, oil, flavoring (diacetyl and spices)Mix salt, oil, flavoring (diacetyl and spices) Combine mixture with cornCombine mixture with corn Pack in single-serving bagsPack in single-serving bags

Air SamplingAir Sampling

►Orders of magnitude of difference Orders of magnitude of difference throughout the plantthroughout the plant

►Highest in mixing roomHighest in mixing room

Worker PopulationWorker Population

►425 in the entire plant, 1992-2000425 in the entire plant, 1992-2000►Only 13 ever worked in mixingOnly 13 ever worked in mixing►4 of the 8 with BO worked in mixing4 of the 8 with BO worked in mixing►Other 4 were packersOther 4 were packers

►BO in gen pop: 1:40,000 to 1:100,000BO in gen pop: 1:40,000 to 1:100,000►No other cases in surrounding No other cases in surrounding

communitycommunity

Animal StudiesAnimal Studies

►Rats exposed to vapors of flavorings Rats exposed to vapors of flavorings for 24 hoursfor 24 hours

►Severe upper and lower airway Severe upper and lower airway changeschanges

Flavoring MakersFlavoring Makers

►Employees in full respirators since Employees in full respirators since 19941994

►Product labeled as “irritating.”Product labeled as “irritating.”►Material Safety Data Sheet not reflect Material Safety Data Sheet not reflect

inhalation hazard until 2005.inhalation hazard until 2005.

RepercussionsRepercussions

►2001: NIOSH reports link2001: NIOSH reports link►2002: published in JOEM, NEJM2002: published in JOEM, NEJM►Dec 2003: NIOSH AlertDec 2003: NIOSH Alert► Institute ventilation/personal protectionInstitute ventilation/personal protection►2007: OSHA plans to inspect all plants2007: OSHA plans to inspect all plants►2007: 100 cases settled, 500 pending2007: 100 cases settled, 500 pending►2008: planned elimination of diacetyl2008: planned elimination of diacetyl►2009: Consumer cases???2009: Consumer cases???

The other white meat diseaseThe other white meat disease

Quality Pork/HormelQuality Pork/Hormel

Mystery illnessMystery illness

►Dec 2006: Hispanic pork worker with Dec 2006: Hispanic pork worker with weakness of legs, “felt heavy.”weakness of legs, “felt heavy.”

►Exam: loss of reflex, mild weaknessExam: loss of reflex, mild weakness►LP: elevated protein, few WBCsLP: elevated protein, few WBCs►MRI: inflammation of cordMRI: inflammation of cord►EMG: decreased conductionEMG: decreased conduction►Dx: autoimmune reactionDx: autoimmune reaction►Tx: steroidsTx: steroids►Relapse weeks after return to workRelapse weeks after return to work

Progressive Inflammatory Progressive Inflammatory Neuropathy (PIN)Neuropathy (PIN)

► My preference: My preference: Progressive Progressive InflammatoryInflammatory

Gliopathy (PIG)Gliopathy (PIG)

First suspicionFirst suspicion

► Sept 2007: Spanish Sept 2007: Spanish interpreter to Dr. interpreter to Dr. Schindler: “What’s a Schindler: “What’s a neuropathy?”neuropathy?”

► Case reviewCase review► Report to QPP EHReport to QPP EH► Report to MDHReport to MDH► Report to Mayo NeuroReport to Mayo Neuro► Report to CDCReport to CDC► 12 patients by Nov 0712 patients by Nov 07

Plant Inspection, 11/07Plant Inspection, 11/07

►All 12 twelve cases worked in “warm room”All 12 twelve cases worked in “warm room”►PIN cases were 7 times more likely than PIN cases were 7 times more likely than

other warm room workers to work at head other warm room workers to work at head table, “blowing brains.”table, “blowing brains.” Wear glasses, lab coats, short glovesWear glasses, lab coats, short gloves Insert hose in foramen magnumInsert hose in foramen magnum 70 psi to liquefy brain70 psi to liquefy brain Considerable splatter/aerosolizationConsiderable splatter/aerosolization

► Immediate stop of process.Immediate stop of process.

Survey of other plantsSurvey of other plants

►25 other pork processors25 other pork processors►Only 2 “blew brains”Only 2 “blew brains”►Plant in Indiana had several cases of Plant in Indiana had several cases of

PIN.PIN.

Repercussions/QuestionsRepercussions/Questions

►No new cases, no lawsuitsNo new cases, no lawsuits►What was the cross reaction?What was the cross reaction?►Why a sudden rash of cases?Why a sudden rash of cases?

Started process in 1998Started process in 1998 Same methodSame method

The Road to Occupational The Road to Occupational MedMed

(Amer. Board of Preventive (Amer. Board of Preventive Med)Med)

The PerksThe Perks

►Variety of practiceVariety of practice ClinicianClinician

►Private practicePrivate practice►Group/hospital practiceGroup/hospital practice

CorporateCorporate►PlantPlant►ExecutiveExecutive

ConsultingConsulting AcademicsAcademics

No call, no weekends, no No call, no weekends, no hospital rounds, …hospital rounds, …

The EndThe End