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Fitness to Work & Safety Sensitive Occupations

Fitness to Work & Safety Sensitive Occupations. Chris Stewart-Patterson MD Occupational Physician Program Director Harvard Medical School. Safety Sensitive?. Danger to self Danger to work mates Danger to general public Pre-placement examination Periodic examinations

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Fitness to Work & Safety Sensitive Occupations

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  1. Fitness to Work & Safety Sensitive Occupations Chris Stewart-Patterson MD Occupational Physician Program Director Harvard Medical School

  2. Safety Sensitive? • Danger to self • Danger to work mates • Danger to general public • Pre-placement examination • Periodic examinations • Fitness to return to work

  3. Safety Sensitive Fitness to Work • Demonstrate normal or adequate function • Good health after acute condition • Chronic disease in remission • Chronic disease with documented period of medical stability • No immanent relapse potential • No risk of sudden incapacitation • 1% guideline?

  4. Safety Sensitive Work Assessment Know the medical aspects of the industry • Ideally job site visits • Job descriptions • Job demands analysis • Bonafide occupational requirements? • Specific medical fitness guidelines • Exclusionary diagnosis? • Exclusionary treatment or medications?

  5. NFPA Essential Duties • Firefighting tasks… • Wear SCBA • Exposure to toxic fumes • 6 or more flight of stairs • Wear fire personal protection ensemble • 50lb (+20 to 40 lb tools) 11. Complex problem solving 13. Sudden incapacitation can result in death

  6. VFRS JDA Maximal values for active fire suppression • Lift 50 kg • Carry 50 kg • Push 100 kg • Pull 100 kg • Time pressure constant • Attention to detail constant

  7. Occupational Medicine Guides • Industry • Railway Association of Canada • CMA Driver’s guide 7th Ed • NFPA occupational medicine guides • ACOEM LEO medical evaluation guides • U.S. DOT Commercial Driver • Medical • AAPL Practice Guideline Psychiatric Disability • Fitness to Work: The Medical Aspects 4th ed • K Palmer et al • AMA Guides to the Evaluation of Work Ability & RTW

  8. ACOEM LEO Medication Guides Medication categories • Acceptable– unlikely to adversely impact job functions. • Temporary – consider restrictions at the beginning of treatment to assess possible side effects • Shift – may be taken while off duty with adequate time before returning to duty. • Restricted – known to have an effect that will very likely adversely impact safety or performance of job functions • Diagnosis – the diagnosis for which the medication is prescribed may require evaluation

  9. Seizures, Diabetes & CAD Fitness to Work References & resources: • RAC • CMA Driver’s guide 7th Ed • NFPA guides • U.S DOT commercial drivers • ACOEM LEO (not seizures yet…)

  10. Hardest FTW Assessment? A valued safety-sensitive worker • Finishes residential treatment • “I’ve stopped using/drinking” But fit to work….? 1) Chronic limitation? 2) What is risk of relapse? 3) Co-morbid conditions? 4) Denial?

  11. Hidden Substance Use Disorder Impairment • Undiagnosed comorbid conditions • Denial is a part of dependence • Unrecognized severity of impairment • Cognitive • Sleep disruption • Adaptation • Active deception: Faking well? • Co-workers or family cover up?

  12. Chronic Alcohol Use Disorder Comorbidity • Psychiatric comorbidity • Dependence/abuse comorbidity • Medical comorbidity • Hepatitis & Cirrhosis • Wernicke’s encephalopathy & Korsakoff’s amnesia • Cardiomyopathy • Peptic ulcer disease • Many more ….. • Comorbid conditions contraindicated?

  13. Cognitive Testing Screening • Mental status examination • Trail Making Tests A & B • Online neuropsychological screening • Review safety protocols • If abnormal results…. • Still abstinent? • Full neuropsychological testing battery?

  14. Trail Making Test B

  15. SUD RTW Cases • Early Wernicke’s encephalopathy • Alcoholism & post CVA • Anoxic brain injury # 1 • Anoxic brain injury # 2

  16. Confirm SUD Treatment • Monitoring with unannounced testing? • Ongoing treatment • Primary substance use disorder • Psychiatric comorbidity • Medical comorbidity • Relapse prevention plan • Social support • Avoid environmental cues • Sleep management plan!!!!

  17. Physician Relapse Study • Retrospective cohort study of 292 MD/PAs • 25% had at least 1 relapse in 10yrs • Relapse risk after the first relapse: HR 1.69 • A family history of an SUD: HR of 2.29 • Major opioid use with coexisting psychiatric disorder: HR of 5.79 • All 3 factors — major opioid use, dual diagnosis, and family history: HR of 13.25 • Domino K.B et al. JAMA. 2005;293:1453-1460

  18. RAC SUD Medical Guides Individuals with DSM IV Substance Dependence must: • Have documented abstinence for 3 months • Complete an intensive addiction treatment program • Agree to participate in a Monitoring Process • Comply with a Relapse Prevention Agreement for at least two years • Demonstrate total abstinence as long as they remain employed in a safety critical position

  19. Diagnosis & impairment Capacity & limitations? Risk & restrictions? Fit to work? Review industry RTW SUD guidelines +/-Follow up review of performance & attendance +/- Follow up occupational medical evaluation Assessing Fitness for Safety Sensitive Work

  20. If in doubt… • Second Occ Med opinion • Specialist review • Return to non-safety sensitive work trial • Attendance reports • Performance reports • Re-assess • Supervised RTW

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