Assessment of occupational injuries. Case 05 - Back Pain from a Minor Fall

1. Assessment of occupational injuries.Case 05 - Back Pain from a Minor Fall

2. Definitions International Labour Organisation defines Occupational injury as "any personal injury, disease or death resulting from an occupational accident". An occupational disease was defined as "a disease contracted as a result of an exposure over a period of time to risk factors arising from work activity". International Labour Organisation 1998. (ABS, 2008) Examples Occupation Diseases/conditions • Chronic and Acute Musculoskeletal injuries due to trauma, overuse • Cutaneous burns, cuts etc but also exposure to irritants and allergens • Noise indued hearing loss, eye trauma etc. • Occupational Lung disorders : Australia rating highest in asbestos cancer in the world • Cardiovascular: Stress, carbon monoxide, carbon disulfide, hydrocarbon solvents • Haematology: lead anaemia, benzene and methyl cellosolve  leukaemia, Arsine gas  massive hemolysis • Gastrointestinal: Diarrhoea, Acute chemical hepatitis • Renal: Acute tubular necrosis (toxins) or Interstitial nephritis chronic exposure to heavy metals • Infections: Leptospirosis (Leptospira interrogans) sewage works/flood waters • Psychological: post-traumatic stress, Neurotoxic disorders due to Acetylcholinesterase inhibition etc. • Reproductive: spontaneous abortions

3. Introduction • Occupational injuries have an important place in primary care practice, emergency medicine and various medical specialties. • A patient's reported occupational history may provide an important opportunity for prevention of future illnesses or injuries • Diagnose and treat workplace injuries • May be required to make follow-up assessments of impairment, disability, and workers' compensation. • To be effective, physicians need to know how to take a good environmental/occupational history and have a reasonable understanding of common environmentally related illnesses

4. Presentation • Not all patients will walk in say “I did X at work” • Work exposures can cause or aggravate a variety of common diseases that do not have unique clinical presentations eg. • asthma caused by latex allergy does not differ from asthma precipitated by a cat allergy; • headache due to carbon monoxide poisoning can be mistaken for severe tension headache or migraine. • Some exposures cause immediate symptoms, thus presentation (allergic reactions and acute chemical reactions), while others lead to more delayed effects (cancer or pneumoconiosis). • The distinguishing feature is the linkage to an environmental or occupational exposure, which the patient themselves may not have made…….. Thus you will need to elicit via History

5. History • Take an occupational history of all patients keeping the presenting complaint in mind, looking for clues suggesting a relationship to activities at work • Questions may include a list of current and longest held jobs, a brief current job description • Find a temporal relationship between symptoms and exposure, but realize that prolonged exposure can lead to the persistence of symptom beyond the work week, while other diseases such as asbestosis occur with a long latency. • Start with non-suggestive questions such as, "Are your symptoms better or worse at home or at work? Weekends or work days?“ • Any suggestion that the symptoms may work related then must obtain additional information about potential exposures • the place of employment and products manufactured, description of tasks he/she performs, the agents handled, and the working conditions. MSK issue- are you required to do any lifting, repetitive movements? • Once it is clear what is being handled, determine was there an opportunity for actual exposure and the mode of entry? • How is the substance handled: What are the operating or cleanup practices? What protective measures are used? What type of ventilation and exhaust is provided? Does the worker need to wear a respirator? Inhaled VS skin contact. MSK- Do you follow safe lifting protocol? • Also consider if the person may be particularly vulnerable to the exposure. Eg. Pregnancy, renal disease, respiratory disease. MSK- Does the patient have osteoporosis

6. Investigations •  If the history raises concerns about exposures, it is usually necessary to measure the exposure in order to assess the level of risk and/or relationship to any symptoms. • Carboxyhemoglobin is a blood test that indicates exposure to carbon monoxide • Arsenic is excreted rapidly in the urine within a few days; it is a good marker for recent but not past exposure. • a blood lead concentration could be ordered to assess exposure, and BUN and creatinine to look for effects upon the kidneys. • Pulmonary function tests and a chest radiograph would be ordered to assess the effects of past asbestos exposure on the lungs. • Xrays for back pains • May need to refer/seek assistance from specialists such as occupational medicine specialists, toxicologists, governmental agencies, and industrial hygienists. • Assessment of musculoskeletal stresses can be performed qualitatively by observing the worker performing job tasks, and more quantitatively with biomechanical analyses performed by an ergonomics expert.

7. Follow up • Arrange/suggest occupational time off work/modification of role (eg less lifting) • The practitioner can also help an affected worker obtain workers' compensation when justified. • It is important to consider whether others have been exposed and need to be evaluated and treated once the diagnosis of a work- or environment-related illness has been made. • The physician may find it necessary to alert the company medical department, a company health and safety committee, or the state public health or labour department

8. Occupational Backpain… • 37% of LBP worldwide is work related • 15% of burden of work related disease • Psychosocial Yellow Flags – risk factors for chronicity • Expectation that pain will increase with work and activity; pending litigation; problems with worker's compensation or claims; poor job satisfaction; unsupportive work environment

9. OH&S • Occupational Injuries are preventable • The goal of all occupational health and safety programs is to foster a safe work environment.” Employers Obligation • Provide and maintaining a safe and healthy work environment • Provide and maintaining safe plant • Ensure the safe use, handling, storage and transport of substances • Ensure safe systems of work • Provide information, instruction, training and supervision to ensure health and safety. Employees Obligations • Comply with instructions given for workplace health and safety • Use personal protective equipment if the employer provides it and if you are properly instructed in its use • Not wilfully or recklessly interfere with or misuse anything provided for workplace health and safety at the workplace • Not wilfully place others at risk

10. References • Olsen, K. Evaluation of patients with occupational chemical exposure. Poisoning & Drug Overdose, 5e. Accessed: www.accessmedicine.com • Goldman, R. 2010. Overview of occupational and environmental health. Accessed: http://www.uptodate.com • ABS. 2007. Labour Statistics: Concepts, Sources and Methods. Accessed: www.abs.gov.au