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. Firefighting tasks…

2. Wear SCBA

3. Exposure to toxic fumes

4. 6 or more flight of stairs

5. 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– 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

• 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 disorder2. Psychiatric comorbidity3. 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