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
• Fitness to return to
work
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?
Safety Sensitive Work Assessment
Know the medical aspects of the industry
1. Ideally job site visits
2. Job descriptions
3. Job demands analysis
4. Bonafide occupational requirements?
5. Specific medical fitness guidelines
– Exclusionary diagnosis?
– Exclusionary treatment or medications?
NFPA Essential Duties
1.
2.
3.
4.
5.
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
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
Occupational Medicine Guides
• Industry
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–
–
–
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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
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
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…)
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?
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?
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?
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?
Trail Making Test B
SUD RTW Cases
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•
•
•
Early Wernicke’s encephalopathy
Alcoholism & post CVA
Anoxic brain injury # 1
Anoxic brain injury # 2
Confirm SUD Treatment
•
•
Monitoring with unannounced testing?
Ongoing treatment
1. Primary substance use disorder
2. Psychiatric comorbidity
3. Medical comorbidity
•
Relapse prevention plan
– Social support
– Avoid environmental cues
– Sleep management plan!!!!
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
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
Assessing Fitness for Safety
Sensitive Work
•
•
•
•
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
If in doubt…
• Second Occ Med opinion
• Specialist review
• Return to non-safety sensitive work trial
– Attendance reports
– Performance reports
• Re-assess
• Supervised RTW