Occupational Medicine Whazzat The Rodney Dangerfields of medicine

Occupational Medicine: Whazzat? The Rodney Dangerfields of medicine William G. Buchta, MD, MPH February 25, 2009

Key Points ► Population focus for § Individuals § Groups ► Hazard/risk analysis ► Special ethics/roles ► Causation ► The perks

Population Focus ► Public health for working population § Healthier § Narrower age range § Special skills § Special physical attributes § Typically not ones to see doctors ► Seeing the patient in context of work ► Remembering the denominator

Seeing the patient in context of work ► Post-offer pre-placement evaluation § Job description § Job-appropriate medical evaluation § Risk assessment § Communication ► Injury/illness evaluation and treatment § Work-related § Non-work-related

Non-work-related illness/injury ► Acute infection: MRSA, URI, AGE ► Sports injury ► Chronic disease § Hepatitis § Diabetes § Ischemic heart disease § Depression/anxiety § Arthritis

Work-related injury/illness ► Low back pain ► Lacerations ► Eye injuries ► Dermatitis ► Lung disease ► Hepatitis ► Cancer ► Death by crush, fall, explosion, asphyxia, gunshot, freezing, burning, etc.

Examples ► Lung disease: pneumoconioses, asthma ► Cancer: bladder, lung, skin ► CV toxicity: CO, methylene chloride ► Reproductive: DBCP, methotrexate ► Nervous system: Hexane, manganese ► Dermatitis: metal-working fluid, cement ► Psychological: burn-out, depression, PTSD ► MSK: tendonitis, epicondylitis, 1 st MCP DJD, NOT carpal tunnel syndrome

Worker Compensation ► One of most misunderstood medical plans ► Different in each state ► 100% medical coverage ► 2/3 pay for time off ► Monetary and rehab benefits for permanent impairment (PPD at MMI) § Per statute 5223 in Minnesota ► Administrative law; no option to sue employer ► Pays 85% or better of U & C charges ► Our contribution to maintaining a healthy workforce

Social Security Disability ► Covers workers disabled from work for any medical reason ► Off work for 1 year or more ► Requires application, medical verification ► Reviewed every 3 to 7 years ► Subsistence payments ► May include Medicare ► NOT heaven on earth

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

And now for some graphic examples…. ► The power of gravity ► The hazardous ladder http: //www. youtube. com/watch? v=0189 LO 5 Fyq. M http: //www. youtube. com/watch? v=xb. Va. XHUu_qc ► Crane gone crazy http: //www. youtube. com/watch? v=5 WQPfb. EFprk ► Steel mills http: //www. youtube. com/watch? v=_hlfqgg. GOZw

More examples … ► Aircraft carrier http: //www. youtube. com/watch? v=4 Ch. D 8 TMI 3 p 8 ► Salt mines http: //www. youtube. com/watch? v=Bi 9 b. Jh. RZt. KA ► Tanneries http: //www. youtube. com/watch? v=2 AS 6 p. AWR 9 n 4

Even more examples … ► Office stress. So, this is light duty? § http: //www. youtube. com/watch? v=s 5 q. HLPbv. I 5 I § http: //www. youtube. com/watch? v=s. TJc. BHA 9 bh. M ► Sex discrimination at work § http: //www. youtube. com/watch? v=go. OHAh. HEU_I § http: //www. youtube. com/watch? v=Whswq. Zh 2 Rc 4 § http: //www. youtube. com/watch? v=R 9 Zf. IFQQvzc

Special Ethics ► Serve the employee or employer? ► Medical evaluation without doctor/patient relationship ► Communication of medical status to § HR (FMLA, ADAAA, job fitness) § Safety staff § Insurer § Supervisor (HIPAA)

Forensic/Hazard Evaluations ► Safety-sensitive jobs § Truck drivers § Pilots/Air traffic controllers § Nuclear power plant workers ► Particular job categories § Lead workers (blood lead) § Asbestos workers (CXR) § Oncology nurses/pharmacists (Surveys) § Radiologists (badges)

Causation: Sherlock Holmes role ► Historical § 1500 s, Paracelsus, “Dose is the poison. ” § 1600 s, Ramazzini, Diseases of Workers § 1700 s, Percival Potts, scrotal cancer in chimney sweeps § 1900 s ►Alice Hamilton, Exploring the Dangerous Trades ►Harriet Hardy, berylliosis registry in industry ►Irving Selikoff, asbestos-related diseases among industrial workers

Austin Bradford Hill statistician 1954, British Doctor Study http: //www. youtube. com/watch? v=nw. Vxuu 6 Ugmg 1. 2. 3. 4. 5. 6. 7. 8. 9. Strength of association Consistency Specificity Temporality Biological gradient (dose/response) Plausibility Coherence Experiment Analogy

NOEL vs. Hormesis Uranium miners Lung cancer Radiation from Radon

Recent Discoveries ►A mystery in Missouri ► The other white meat disease

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

Common Characteristics ► Symptoms: dyspnea on exertion, cough ► Exam: decreased sounds, basilar rales ► Tests: § CXR: lung expansion § PFTs: non-reversible obstruction § Diffusing capacity: normal § CT: air trapping, bronchiectasis § Lung biopsy: bronchiolar fibrosis/narrowing

Bronchiolitis obliterans

Popcorn Plant ► Process § § § Mix salt, oil, flavoring (diacetyl and spices) Combine mixture with corn Pack in single-serving bags

Air Sampling ► Orders of magnitude of difference throughout the plant ► Highest in mixing room

Worker Population ► 425 in the entire plant, 1992 -2000 ► Only 13 ever worked in mixing ► 4 of the 8 with BO worked in mixing ► Other 4 were packers ► BO in gen pop: 1: 40, 000 to 1: 100, 000 ► No other cases in surrounding community

Animal Studies ► Rats exposed to vapors of flavorings for 24 hours ► Severe upper and lower airway changes

Flavoring Makers ► Employees in full respirators since 1994 ► Product labeled as “irritating. ” ► Material Safety Data Sheet not reflect inhalation hazard until 2005.

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

The other white meat disease

Quality Pork/Hormel

Mystery illness ► Dec 2006: Hispanic pork worker with weakness of legs, “felt heavy. ” ► Exam: loss of reflex, mild weakness ► LP: elevated protein, few WBCs ► MRI: inflammation of cord ► EMG: decreased conduction ► Dx: autoimmune reaction ► Tx: steroids ► Relapse weeks after return to work

Progressive Inflammatory Neuropathy (PIN) ► My preference: Progressive Inflammatory Gliopathy (PIG)

First suspicion ► Sept 2007: Spanish interpreter to Dr. Schindler: “What’s a neuropathy? ” ► Case review ► Report to QPP EH ► Report to MDH ► Report to Mayo Neuro ► Report to CDC ► 12 patients by Nov 07

Plant Inspection, 11/07 ► All 12 twelve cases worked in “warm room” ► PIN cases were 7 times more likely than other warm room workers to work at head table, “blowing brains. ” § Wear glasses, lab coats, short gloves § Insert hose in foramen magnum § 70 psi to liquefy brain § Considerable splatter/aerosolization ► Immediate stop of process.

Survey of other plants ► 25 other pork processors ► Only 2 “blew brains” ► Plant in Indiana had several cases of PIN.

Repercussions/Questions ► No new cases, no lawsuits ► What was the cross reaction? ► Why a sudden rash of cases? § Started process in 1998 § Same method

The Road to Occupational Med (Amer. Board of Preventive Med)

The Perks ► Variety of practice § Clinician ►Private practice ►Group/hospital practice § Corporate ►Plant ►Executive § Consulting § Academics

No call, no weekends, no hospital rounds, …

The End