Enhancing Occupational Medicine Practice: Communication, Consultation, and Compassion

1. Mastromatteo OrationOccupational Medicine in Atlantic CanadaOEMAC AGM Saskatoon – 2010 Ciaran O’Shea, MD, FCBOM

2. Outline of the Presentation • Introduction • The four “C’s” of Occupational Medical practice • Three occupational health scenarios • Some suggestions which I believe may enhance your practiceof Occupational Medicine

3. Introduction • GP 1974 to 1990 : Early involvement ; fitness to dive medical assessments • OEMAC membership and mentorship and direction by senior colleagues • ACBOM, subsequent CCBOM, full-time occupational medicine 1990 • Atlantic Offshore Medical Services 1978

4. The Four “C’s” of Occupational Medical Practice • COMMUNICATION • CONSULTATION • CONTAINMENT • COMPASSION

5. Scenario 1 – Consultation & Communication • Routine OHS inspection of a marine vessel reveals damaged asbestos-containing material – exposure to friable asbestos • Partial communication to crew – erection of extensive signage re: Danger, asbestos exposure, PPE, etc • Immediate labour and media outrage: panic-stricken crew (employees / families) – fueled by persistent media comment

6. Occupational Medical Input • Review IH info and vessel history, crewing etc. • Extensive review of topic and consultation with colleagues re: best approach • Develop health surveillance protocol for crew members initially and others exposed (< 1000) • Develop presentation to communicate health risks

7. Presentation Format • Define Asbestos, its usage, where it’s found today • Review the types and incidence of known asbestos-related disease • Confirm the exposure, outline absolute possibility of disease but low probability • Communicate a clear picture of disease patterns in North America known to be asbestos related • Outline a proposed health surveillance plan (voluntary)

8. Health Surveillance Protocol / Procedure • Demographics, known work history, etc. supplied by company • Consent process for examination and handling of medical information • Asbestos health questionnaire and targeted medical / RN examination • PFTs, base-line chest x-ray (discussion with Radiology and specific x-ray requisition) and dip urinalysis

9. Further Investigation and Follow-up • High resolution CT Scan as per Radiologist • Consultation with Respirology • Follow-up CXR – 3 to 5 years (ATS)

10. Individual Health Risk Management • Smoking cessation • Inclusion of asbestos exposure in heath history • In the event of cancer diagnosis (lung, larynx, GI, kidney, etc.) have GP report to WCB • WCB will review occupational health history disease relatedness, etc.

11. Handling of Results of Health Surveillance • Advice given at time of physician / nursing examination • Formal letter to employee / patient • Formal letter to family physician. • Global results communicated to employer

12. How were the Presentations received ? • Numerous presentations generally well received. Alleviated a lot of anxiety, anger, fear and concern • Need to separate objectives of presentation from issues regarding blame, liability, etc. • Concerns expressed re: deceased workers and potential relationship to exposure • Multiple personal consultations after each presentation

13. Assessment Results • 432 Health assessments • 358 Health assessment completed (74 x-rays not done) • 217 No abnormalities detected • 121 Minor abnormalities likely unrelated to asbestos • 20 Minor abnormalities possibly related to asbestos

14. WCB Claims Experience to date 9 WCB claims filed 2 claims accepted Chief Engineer 41 year interval, pleural plaques, non small cell lung CA Assistant Steward, 49 year interval, asbestosis, plaques, non small cell lung CA

15. Scenario 2 – Containment & Communication • Major multidisciplinary emergency response exercise in Atlantic Canada. (Marine Ferry , CCG, RCMP, SAR, Emergency Preparedness Canada, Western (NL) Health Authority, CDN Red Cross and others • 60 + volunteers from Provincial Search and Rescue Organization participated as ferry passengers • Day 1 – Hostile takeover of ferry • Day 2 – Evacuation of passengers from disabled ferry via lifeboat to nearby CCG vessel

16. The Problem Begins… • Day 1 and 2 all going well until lifeboat 4 disembarks its 17 passengers to the CCG vessel • Lifeboat 4 – passengers all ill, varying degrees of nausea, vomiting, dizziness, weakness, drowsiness and 1 case of loss of consciousness • Exercise halted by Captain of the CCG vessel. All passengers administered 02 and advanced level first aid • All passengers transferred to the local secondary care facility for assessment and management

17. Management in the Emergency Department • Carbon Monoxide poisoning / fume ingestion suspected - consultation hyperbaric MD • Formal Carboxyhaemoglobin measurements not available at the time • Bloods drawn and sent to St. John’s for analysis • 1 patient LOC/drowsiness (intubated) and 2 others ? CO poisoning to St. John’s for hyperbaric oxygen • Others responded and settled apart from minor symptoms

18. In the Interim, Complicating Factors • Inaccurate media report from CCG suggesting fire, etc. on lifeboat no. 4 • Vessel company press release, no evidence of fire, etc. • Extensive media coverage “Mystery Illness, etc. on Exercise, Cause Unknown” • Later on vessel owner reports no air quality problems following extensive testing of lifeboat no. 4

19. Vessel Owner Consultation with Occupational Physician • Review of Carbon Monoxide poisoning • Initial discussion with treating hyperbaric physician –likely CO toxicity • Passengers constantly in touch with this MD, polysymptomatic, angry, infuriated by Co. statements • Company cannot explain incident at this time • What would you as the advising Occ Doc do ?

20. Contain and Manage the Problem • Information session ( Q&A) for all those affected as soon as possible • Employer HR, Hyperbaric Physician, Neurologist and myself present • Full acknowledgement of health impact on these individuals, including the likely possibility of CO poisoning and / or other contributing factors • Offer a voluntary individual neurological evaluation and review of all information relevant to the event

21. Referral Letter to the Neurologist • Review each patient’s account of their experience in terms of ill effects and review hospital health records • Review each patient’s observations while in the lifeboat enroute to the CCG vessel • Initiate any appropriate medical follow-up and pursue any medical investigation as required • Provide each patient with your opinion regarding the nature of their concerns, the relationship to CO and your prognosis regarding future health issues

22. Final Report from Neurologist Suggested • 12 of 17 patients assessed, all became ill to varying degrees – vessel operators asymptomatic • Illness was induced by motion sickness, nauseous fume inhalation, as well as local environmental stressors (confined space, others vomiting, etc.) all compounded by a stressed emotional atmosphere • Majority completely resolved over the coming days and weeks • 2 patients : symptoms of PTSD 1 patient : STI Neck 2 patients : Iatrogenic middle ear barotrauma

23. Closing Comments from Neurology • Suspicion of potential carbon monoxide poisoning was correct, and hyperbaric O2 treatment reasonable • Subsequent investigation and review of all information supported a conclusion that clinically significant carbon monoxide exposure did not occur in this patient population • No follow up indicated or requested by patients themselves

24. Key Points – Carbon Monoxide and Asbestos Scenarios • If employee population affected by acute health hazard or ongoing chronic health hazard, immediate intervention required • Research topic fully and any IH information • Communicate all factual information re: situation and health effects to employee group • Offer individual health assessments on a compassionate / confidential basis • Consider ongoing health care and health risk management as a result of exposure

25. Scenario 3 – Compassion & Communication • Transportation to and from offshore and Oil and Gas Installations in Eastern Canada • The role of Atlantic Offshore Medical Services (AOMS) • Offshore related disasters

26. Loss of Cougar Flight 491 – March 2009 • 10:20 am call from Cougar, helicopter ditching 35 miles east of St. John’s, 17 onboard • 10:30 am Operator confirmation of the incident • 10:30 am to 10:50am Notification Tertiary Health Care, 1st on-call Medevac Teams, AOMS Office Physicians, EAP / Counseling services to ensure a state of readiness • 11:00 am operator call confirming involvement of AOMS employee. Fly over indicates helicopter on surface and life rafts inflated

27. In House AOMS Response • Contain event-related information in-house; tight control of incoming media calls, etc. • Management to relay accurate information in-house as it unfolds • Instances where inappropriate information was received • Management team members placed on full alert

28. The Reality of the Situation – Late Afternoon • 1 injured survivor and 1 body retrieved from the water; life rafts empty; no evidence of survivors • AOMS facilitates transportation and meets next of kin on arrival in St. John’s • Formal notification of next of kin and family members; designated facility / hotel setup established • AOMS Management personnel support families during recurrent debriefings

29. Ensure the Integrity of AOMS Services • Arrange alternate medevac systems on a temporary basis • Individual calls to on duty and off duty offshore medics, NL and NS • General staff meeting to update all on the events to date • Impact on offshore helicopter travel; prepare for employee transport by vessel

30. Next of Kin Support • Senior Physicians, HR and Management meeting with widow, parents, and family members of the AOMS medic • Meeting with the AOMS Case Manager who lost her spouse • Recommendation of counseling and support services to all parties, and offer of support in any which way that we could • Notification of AOMS Insurers / Benefits Consultants

31. Concluding Practice Suggestions • Formal introduction to each patient communication /compassion/containment • Respect and protect the patient - treating physician relationship communication/compassion • Ensure Medical decisions /advice supportable by peer review and meet applicable legislation communication /consultation • Consult with peers and experts in Occupational Medicine as necessary communication /consultation

32. Communicate Occupational Health Policy and Program to Management and Employee Reps prior to implementation communication /containment • Understand and respect the business needs of your client but never compromise the ethics or principles of practice of Occupational Medicine communication /consultation/compassion