Prompt and effective treatment of the injured worker can save that individual from unnecessary disability. An early return to work, when medically indicated, can also assist in rehabilitation. Acute care in an occupational health care setting, however, is more than a simple service function as it might be in a hospital emergency room. Rather, opportunities should exist within a well-organized occupational health care system to use the lessons learned from each injury, either singly or as aggregate statistical data, to prevent future injuries. The ultimate goal of an occupational health intervention, of course, is to control the hazard that led to the problem in the first place.
Acute care refers to the provision of care for both occupational disorders and non-occupational disorders occurring in the workplace. Acute care of the injured worker is the most basic form of occupational medical care and usually involves the treatment of injuries.
Most occupational injuries are straightforward to manage. The majority of are soft-tissue lesions, particularly strains and sprains. Physiotherapy plays a particularly important role in the early rehabilitation of injured workers and should be used liberally. Each occupational injury represents a failure of the system at some level to prevent accidents; the pattern of injuries is therefore a guide to the safety specialist and the responsible supervisors to identify the factors leading to a repetition of injuries in the workplace. The occupational medical service is often involved in rehabilitation to a greater degree than general surgical or medical clinics. Frequent visits to physiotherapy provide a rather inexpensive but accurate means of monitoring the progress of recovery as objectively measured by indicators of function: mobility, strength, coordination, and stability. The physiotherapist can monitor and report on a patient's progress at far less expense than a physician.
Back injuries alone account for one-quarter of all occupational injuries and present particular management problems because of their often chronic nature and subjective symptoms. It is essential that any occupational health service be prepared to deal with back injuries. This means medical and nursing personnel trained in the latest thinking on the subject and consideration of preventive programs for employees, such as the so-called "back-schools" that teach lifting and back care techniques. It also means that attention must be paid to actual work practices, whether on a factory floor or in an office filing room to avoid back injuries through poor lifting habits and inadequate help in the task. Routine back films for employees to screen out individuals susceptible to back injury are completely unreliable, discriminatory to persons with silent defects, and require an unacceptably high radiation exposure for a screening test.
Other body parts frequently involved in occupational injuries include the extremities and trunk. Most such accidents are soft-tissue injuries or cuts and seldom result in permanent disability, although hand and foot injuries can become management problems because of the ease of reinjury or difficulty in regaining function after remobilization. Eye injuries have the potential for serious disability and anything beyond superficial foreign bodies and conjunctivitis should probably be managed by an ophthalmologist if one is available.
Early return to work appears to speed up recovery, both by returning the patient to familiar body movement and by resocializing the patient into a more normal life. Three months following the injury seems to be a critical point beyond which a delay in returning to work is associated with a reduced probability of ever returning and increased levels of disability, taking into account the severity of the injury. It is thus to the advantage of employers to accept injured employees back on the job for light duty assignments whenever possible; unfortunately many do not because they fear liability for reinjury or for a second injury.
Following acute care, the physician is expected to follow the patient periodically, providing "supplemental reports" as needed to the employer and workers' compensation board and a "final report" when the patient is either fit to return to work or reaches a permanent level of disability from which further improvement is not to be expected. (See Chapter 7.)
Fitness to return to work is not solely a subjective evaluation, although the physician must use judgement. (Fitness-to-work evaluations are discussed in detail in Chapter 18.) Knowledge of the tasks performed on the job and the body movements and strength needed for each is important in evaluating many cases, and a telephone call to the supervisor is usually helpful and much appreciated. Often in private practice there is a tendency to give the patient-employee a few extra days or even weeks off as a concealed paid holiday. This practice is to be condemned, because it not only costs the employer (an estimated $l00 per hour across all industries in North America) but slows the workers' return to a normal life, delays functional recovery, promotes without reason a poor attitude toward the employer and the workers' compensation system, and encourages a psychological defense of retreating into the sick role, which is unhealthy for the employee.
Occupational illness are usually much more difficult to diagnose and to manage than occupational injuries. The proper medical approach to occupational illnesses is best left to a textbook on occupational medicine and is beyond the scope of this book. Except where a particular industry or plant has a pattern of hazardous conditions distorting the frequency of work-related illnesses, the distribution of work-related diseases in industry as a whole tends to follow the "rule of halves", that is the frequency can be approximated by halving the left-over fraction. Skin disorders account for approximately one-half of all occupational diseases, eye conditions frequently related to exposure also causing skin disorders - for about one-quarter, lung disorders for about one-eighth, systemic poisonings for about one-sixteenth, and the remainder include neurologic, cardiac, reproductive, hearing, mental disorders and everything else work-related, including cancer associated with occupational exposures.
An occupational health service must take into account the frequency of these disorders as well as the risks peculiar to the industry in planning the service. Hearing conservation and noise control programs merit particular mention because excessive exposure to noise is a problem common to many industries and workplaces and noise-induced hearing loss is an entirely preventable occupational disorder. Noise-induced hearing loss is one occupational disorder that virtually all services must be prepared to recognize and prevent. Other occupational illnesses vary with the specific hazards of the industry and cannot be generalized easily. An occupational health service must know in advance what to expect and must be prepared.
Chapter 18 presents a general overview of the procedures for evaluating fitness to work and disability. The identification of occupational disorders, the process by which the physician arrives at a conclusion regarding relationship to work and causation, and the assessment of the probable effect of the condition on the individual is covered in detail in the final section of the chapter, disability evaluation.
Conventional medical practice emphasizes the identification, evaluation, and treatment of a disorder. Correction of the underlying problem which has caused the disorder is of equal importance in situations where a hazard persists and may affect others. In occupational medicine the physician often must also be concerned with who presents with an occupational disorder due to a hazard which continues to exist. Obviously, in most cases of cancer or other chronic diseases with long latency periods the exposure which caused the illness is often long gone. Without special training or expertise in occupational health, the physician is not technically qualified to recommend or advise on specific corrective measures and should concentrate on clearly stating the problems. An insensitive or undiplomatic approach can cause great harm to the patient and may even cost the patient his or her job, regardless of the legal protection afforded to the employee.
The physician confronted by an occupational health problem must make several preliminary judgments before suggesting a course of action:
In investigating suspected health effects, it is often useful to look for patterns in the distribution of disease among workers in the particular workplace. This is a preliminary exercise in epidemiology . A clinician or several practitioners in a given area may notice an unusually large number of cases of a particular disorder among workers in a specific industry or workplace. Such patterns may be highly suggestive of an occupational association and some occupational disorders have been discovered in this way, but unless the disorder in question is rare, clusters of cases are seldom evidence of an occupational exposure. The reason for this is that apparent, but not statistically significant, cluster of disorders without identifiable cause are not rare based on chance alone. Underlying demographic features of the population also exert a powerful influence on risk for various health outcomes. These demographic features include age, sex, race, ethnicity, smoking habits, social class, alcohol use, and family relationships. A workforce which consists predominantly of or which includes a large subset from a high-risk population is obviously likely to reflect the health risks associated with that group. For example, a working population consisting predominantly of black Americans is likely to have a high prevalence of hypertension and an elevated incidence of hypertension-related outcomes. A group of machinists, who are predominantly middle-aged white males, will have a proportionately higher incidence of cancer and health outcomes associated with cardiovascular disease, such as angina, sudden death, myocardial infarction, stroke, and peripheral vascular disease. The health experience of a working population should never be accepted as evidence of an occupational exposure without considering carefully the demographic features of the population and the expected incidence of the disease in question among individuals of similar age, sex, race, and ethnic background. Such characteristics of the population can be statistically controlled by a process known as "adjustment" of rates in which the incidence of disease in a given population is compared to that of a standard population, as if the age, sex, and racial distributions were identical. This requires a degree of training and expertise in epidemiology or assistance in the analysis, which may be available through nearby medical schools, schools of public health, and state and the larger county health departments.
The clinician without special training in occupational medicine must be acutely aware of his or her limitations. Without a working knowledge of occupational exposures and industrial hygiene, the physician is in a poor position to prescribe specific controls. That is best left to the experts in safety and industrial hygiene. The clinician can define the problem and clearly describe the health outcomes observed. Likewise, the clinician can inform the unsophisticated employer of the general options available for the solution of the employer's occupational health problems. The responsiveness of the employer, however, depends in no small degree on the approach taken by the physician. Even the most well-meaning attempt to protect the employee may be compromised by an insensitive or overly confrontational approach.
The following are suggested steps which might be taken by physicians who feel that they have identified a potentially significant occupational health hazard:
The clinician who is excited by the possibility of an association may inadvertently overinterpret clinical findings to fit the published descriptions, for example by considering every rash and especially acne vulgaris to be chloracne, a severe acneiform rash associated with dioxin exposure. The clinician may become convinced that patients from his or her represent a new and significant association with a previously unrecognized occupational exposure. There is no doubt that many important occupational hazards have been identified in just this way, such as vinyl chloride-induced liver cancer and dimethylaminoproprionitrile-induced autonomic dysfunction. Identification of an entirely new occupational association is rare, however, and usually occurs in situations where the exposure is unusual in industry, confined to a small group of workers, or only recently introduced. Such possible associations should be investigated further if convincingly plausible, however, and occasionally a previously overlooked health risk or an effect confined to a high-risk subpopulation may be identified in this way.
In dealing with employers, an open line of communication is in the best interests of the patient. Whenever possible, the employer should be given an opportunity to correct the problem before third parties become involved. Attempts to "blind-side" the employer by withholding information or proceeding immediately to legal redress may provoke a strong, sometimes irrational reaction which forces the employer into an uncooperative and adversarial posture. Proceeding methodically as if the employer is committed to resolve the problem is usually the best course, since it provides the employer with a face-saving way out of the dilemma and establishes the good faith effort of the employee for future legal actions. The motives of the leadership of the company are not germane to the solution of the problem, except insofar as these motives provide an opportunity to reason with the management for the benefit of all concerned. The psychology of the relationships between labor and management is much too complex for the clinician to deal with. The more coercive the approach, the more likely it is to provoke resistance. This is particularly true for companies that have made an initial, but inadequate, effort toward developing an occupational safety and health program.
In cases of work-related disease or injury, the physician is required to file a "doctor's first report" with the state of provincial agency responsible for occupational safety and health. (See Chapter 7.) This report initiates the claim of workers' compensation eligibility and is an essential first step in the process of establishing a legally-recognized association with an occupational hazard. Failure to report an occupational illness or injury is technically a violation of the law, although penalties and the likelihood of prosecution of the offending physician varies among jurisdictions. When the patient returns for a follow-up visit or for physical therapy or other long-term treatment, the workers' compensation insurance carrier requires a "supplemental report" on the patient's progress and estimate of the most likely duration of the disability. Conscientious communication with both the employer and the carrier by means of telephone and such formal reports will greatly expedite handling of the patient's case.
Another preliminary step is complete and accurate documentation. At every step of the case, the particulars should be carefully recorded in the medical record, which is subject to subpoena. The recording of accurate data may profoundly affect the resolution of a case, but only after the institution of a claim.
The patient should be advised of his or her rights under the Occupational Safety and Health Act (See Chapter 8), and pertinent state legislation. In particular, the patient should know that it is against federal law for an employer to fire an employee for refusing to work in a hazardous situation and that it is a right of employees as a group to petition OSHA or NIOSH (See Chapter 8) for a workplace inspection. The patient's job security may be jeopardized by a misguided move. Although the law protects workers who complain of unsafe work practices, an employee who is perceived as a "troublemaker" may be singled out for attention and may eventually be fired, nominally for other reasons. Although the employer cannot fire the employee for claiming a work-related injury or illness, the reality of the situation is that any employer can make life miserable for a single employee who complains. Sometimes an employer will search for other reasons, such as excessive absenteeism or poor performance, to terminate the employee.
A certain degree of judgment is required in using these rights constructively. For example, a "hazardous situation" is intended to mean a condition which could lead to serious injury, such as an unlined trench, an unstable scaffold, or a confined space in which gases may accumulate. It does not mean climbing an ordinary ladder or driving a truck, unless there are extraordinary circumstances. The degree of urgency with which the intervention is carried out should match the magnitude of the hazard. A company with a history of fatal accidents should be treated differently than one with an occupational spill of relatively innocuous solvents. The employer may be contacted directly by the physician and advised of the magnitude of the problem. A letter is helpful to document the contact but a telephone call often produces better results. The tone should be nonconfrontational, focused exclusively on the problem at hand, and helpful in conveying the necessary information to allow the employer to address the problem. Most employers do not want trouble with the union, their workers' comp carrier, or OSHA. In spite of one's best efforts, a belligerent or beleaguered employer may respond badly but should always be treated courteously.
The employer, can be informed of the availability of state or federal OSHA consultation services. These services provide a limited, voluntary inspection and technical advice on the specific problem and is free to the employer. Unless an imminent danger exists, the OSHA consultation service limits itself to advising the employer and does not communicate its findings to the enforcement branch. The consultation service was intended to facilitate the solution of problems by employers who lacked the resources of technical knowledge to deal with the problem themselves or to hire outside consultants. Nonetheless, many employers remain reluctant to call OSHA under any circumstances out of fear of enforcement for what might be found.
An OSHA consultation is a good place to start for the small or medium-sized employer. However, the technical level of OSHA consultation services usually are not high since the agencies lack the facilities, time, and manpower to deal with complex problems. For complex or difficult problems, the National Institute for Occupational Safety and Health (NIOSH) may also be of assistance. Certain problems are selected by NIOSH for intensive "health hazard evaluations" as research questions.
The employer then may be led to local or regional resources which can assist in providing solutions. Academic institutions and a few public agencies are available to work on the solutions of particular problems, as are numerous highly talented professional consultants. Private consultation services in occupational safety and health are not cheap and the quality of services provided is inconsistent. Referring employers to academic institutions at least favors a reasonable recommendation in the selection of a consultant.
The worker, along with two other employees or through his or her union, may request an inspection by OSHA. The names of the employees initiating the request will be kept confidential. Inspections fall into four priority categories: (1) imminent danger, when a condition exists that might lead to death or serious physical harm, (2) fatality and catastrophe investigations, (3) investigation of complaints, and (4) routine regional programmed inspections. First priority (imminent danger) inspections are performed within 24 hours and require a tremendous effort on the part of the agency. Fatalities are likewise investigated thoroughly, although they may be less urgent after the fact. Third priority inspections are handled on the basis of severity of the complaint, the number of complaints received by the OSHA office, and the time and the resources available locally. A complete inspection of the workplace is not always made in response to a complaint, especially when the workplace has been inspected recently on a routine basis. In such cases partial inspections are performed, focused on the source of the complaint.
Berstein RS, Lee JS. Recognition and evaluation of occupational health problems, in Rom WN. Environmental and Occupational Medicine. Boston, Little Brown, 1983, pp. 7-19.
Guidotti TL. Occupational medicine. Kansas City, American Academy of Family Practice, Home Study Self-Assessment Monograph 65.
Identification and Control of Work-Related Diseases. Geneva, World Health Organization, Technical Report Series No. 714, 1985.
Imbus HR. Clinical aspects of occupational medicine, in Zenz C. Occupational Medicine: Principles and Practical Applications. Chicago, Year Book Medical Publishers, 1975, pp. 89-107.
Keogh JP. Occupational and environmental disease, in Barker LR, Burton JR, Zieve ZD. Principles of Ambulatory Care. Baltimore, Williams and Wilkins, 2nd ed., 1986, pp. 98-111.