Microsoft powerpoint - cbom intro fitness to work and safety sensitive occupations 2012_chrisstewartpatterson [compatibility mo

Chris Stewart-Patterson, MD, CCBOM, FACOEM • Emphasis on fair & defendable opinions• Short on specifics but heavy on resources!• Look at controversial areas• Brief focus on SUDs & FTW • Danger to self• Danger to work mates• Danger to general • Periodic examination• “Hazmat” • Fitness to return to 5. Wear fire personal protection ensemble 13. Sudden incapacitation can result in death Maximal values for active fire suppression • CMA Driver’s guide, 7th ed.
• Transport Canada Handbook for Civil • ACOEM LEO Medical Evaluation Guides• DOT Medical Examination: A Guide to Commercial Drivers’ Medical Certification • Fitness to Work: The Medical Aspects, • AMA Guides to the Evaluation of Work Impairment is about Inability of a function • Any diagnosis?• Degree of impairment?• Capacity & limitations? • Risk & restrictions?– Temporary or permanent? • Fit to work/Disabled? • Know the job• Review industry RTW SUD guidelines • Demonstrate normal or adequate capacity – Chronic disease with documented period of • No significant risk of sudden incapacitation Worker has capacity but may become incapacitated.
• In addition to fitness to work, the employer • Age & risk appropriate preventive • EEs with severe sleep apnea (RDI > 30) cannot be considered fit to work in an SCP until written confirmation and data have been provided to the medical officer • The individual must be compliant with – “severe uncontrolled” (BP > 180/90) – malignant hypertension (end organ damage) – beta-blockers, high-dose diuretics or clonidine Medication categories• Acceptable – unlikely to adversely impact job • Temporary – consider restrictions initially to • Shift – may be taken while off duty with • Restricted –very likely adversely impact safety or • Diagnosis – the diagnosis for which the medication is prescribed may require evaluation – Know the medical history & job duties – Warned them the medication may impair – Review of a driver-signed form regarding SE, denying current impairment & will stop if impaired • Consider driving hx, psychiatric hx, comorbidity, dose & pharmacokinetics – Parenteral administration (transdermal) • Opioids may be associated with adverse effects that will decrease driving safety • Rx opioids to operators of a commercial motor vehicle or pilot an aircraft generally precludes work • Same for safety-sensitive positions in industry (e.g., forklift, construction, heavy equipment operations) “…certain patients on stable doses of opioids are able to drive provided they.” • Lack co-prescriptions or other substance use that may exert significant CNS effects • Do not experience high levels of pain • No sleep disorder or daytime somnolence • Psychiatric comorbidity is high!• Suspect polysubstance use• Medical comorbidity – Hepatitis & Cirrhosis– Wernicke’s encephalopathy & Korsakoff’s – Cardiomyopathy– Peptic Ulcer – Many more ….
– Full neuropsychological testing battery? • Retrospective cohort study of 292 MD/PAs • 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 • All 3 factors — major opioid use, dual diagnosis, – Domino K.B et al. JAMA. 2005;293:1453-1460 Individuals with DSM-IV Substance Dependencemust:• Have documented abstinence for 3 months • Complete an intensive addiction treatment • Sign and demonstrate compliance with a Relapse Prevention Agreement for a period of at least 2 years of stable abstinent remission • Have a written report provided by a physician • Fitness to Work: The Medical Aspects, • Any diagnosis?• Degree of impairment?• Capacity & limitations? • Risk & restrictions?– Temporary or permanent? • Fit to work/disabled? • Know the job• Review industry RTW SUD guidelines Time per Day
Percentage of Shift
Infrequent
Occasional
Frequent
Constant
• If temporary restrictions or limitations:– How long?– Need reassessment? – Are they at Maximal Medical Improvement? • “The condition has stabilized and is unlikely to change substantially in the next year…” • Return to non-safety sensitive work trial

Source: http://www.cbom.ca/doc/CBOM%20Intro%20Fitness%20To%20Work%20and%20Safety%20Sensitive%20Occupations%202012_ChrisStewartPatterson%20%5BCompatibility%20Mo.pdf