Mastromatteo Oration Occupational Medicine in Atlantic Canada OEMAC

Mastromatteo Oration Occupational Medicine in Atlantic Canada OEMAC AGM Saskatoon – 2010 Ciaran O’Shea, MD, FCBOM 1

Outline of the Presentation n Introduction n The four “C’s” of Occupational Medical practice n Three occupational health scenarios n Some suggestions which I believe may enhance your practice of Occupational Medicine 2

Introduction n n GP 1974 to 1990 : Early involvement ; fitness to dive medical assessments OEMAC membership and mentorship and direction by senior colleagues ACBOM, subsequent CCBOM, full-time occupational medicine 1990 Atlantic Offshore Medical Services 1978 3

The Four “C’s” of Occupational Medical Practice n COMMUNICATION n CONSULTATION n CONTAINMENT n COMPASSION 4

Scenario 1 – Consultation & Communication n Routine OHS inspection of a marine vessel reveals damaged asbestos-containing material – exposure to friable asbestos Partial communication to crew – erection of extensive signage re: Danger, asbestos exposure, PPE, etc Immediate labour and media outrage: panicstricken crew (employees / families) – fueled by persistent media comment 5

Occupational Medical Input n n Review IH info and vessel history, crewing etc. Extensive review of topic and consultation with colleagues re: best approach Develop health surveillance protocol for crew members initially and others exposed (< 1000) Develop presentation to communicate health risks 6

Presentation Format n Define Asbestos, its usage, where it’s found today n Review the types and incidence of known asbestos-related disease n Confirm the exposure, outline absolute possibility of disease but low probability n n Communicate a clear picture of disease patterns in North America known to be asbestos related Outline a proposed health surveillance plan (voluntary) 7

Health Surveillance Protocol / Procedure n n Demographics, known work history, etc. supplied by company Consent process for examination and handling of medical information Asbestos health questionnaire and targeted medical / RN examination PFTs, base-line chest x-ray (discussion with Radiology and specific x-ray requisition) and dip urinalysis 8

Further Investigation and Follow-up n High resolution CT Scan as per Radiologist n Consultation with Respirology n Follow-up CXR – 3 to 5 years (ATS) 9

Individual Health Risk Management n Smoking cessation n Inclusion of asbestos exposure in heath history n n In the event of cancer diagnosis (lung, larynx, GI, kidney, etc. ) have GP report to WCB will review occupational health history disease relatedness, etc. 10

Handling of Results of Health Surveillance n Advice given at time of physician / nursing examination n Formal letter to employee / patient n Formal letter to family physician. n Global results communicated to employer 11

How were the Presentations received ? n n Numerous presentations generally well received. Alleviated a lot of anxiety, anger, fear and concern Need to separate objectives of presentation from issues regarding blame, liability, etc. Concerns expressed re: deceased workers and potential relationship to exposure Multiple personal consultations after each presentation 12

Assessment Results n n n 432 Health assessments 358 Health assessment completed (74 x-rays not done) 217 No abnormalities detected 121 Minor abnormalities likely unrelated to asbestos 20 Minor abnormalities possibly related to asbestos 13

WCB Claims Experience to date 9 WCB claims filed 2 claims accepted Chief Engineer 41 year interval, pleural plaques, non small cell lung CA Assistant Steward, 49 year interval, asbestosis, plaques, non small cell lung CA 14

Scenario 2 – Containment & Communication n n Major multidisciplinary emergency response exercise in Atlantic Canada. (Marine Ferry , CCG, RCMP, SAR, Emergency Preparedness Canada, Western (NL) Health Authority, CDN Red Cross and others 60 + volunteers from Provincial Search and Rescue Organization participated as ferry passengers Day 1 – Hostile takeover of ferry Day 2 – Evacuation of passengers from disabled ferry via lifeboat to nearby CCG vessel 15

The Problem Begins… n n Day 1 and 2 all going well until lifeboat 4 disembarks its 17 passengers to the CCG vessel Lifeboat 4 – passengers all ill, varying degrees of nausea, vomiting, dizziness, weakness, drowsiness and 1 case of loss of consciousness Exercise halted by Captain of the CCG vessel. All passengers administered 02 and advanced level first aid All passengers transferred to the local secondary care facility for assessment and management 16

Management in the Emergency Department n n n Carbon Monoxide poisoning / fume ingestion suspected - consultation hyperbaric MD Formal Carboxyhaemoglobin measurements not available at the time Bloods drawn and sent to St. John’s for analysis 1 patient LOC/drowsiness (intubated) and 2 others ? CO poisoning to St. John’s for hyperbaric oxygen Others responded and settled apart from minor symptoms 17

In the Interim, Complicating Factors n n Inaccurate media report from CCG suggesting fire, etc. on lifeboat no. 4 Vessel company press release, no evidence of fire, etc. Extensive media coverage “Mystery Illness, etc. on Exercise, Cause Unknown” Later on vessel owner reports no air quality problems following extensive testing of lifeboat no. 4 18

Vessel Owner Consultation with Occupational Physician n Review of Carbon Monoxide poisoning Initial discussion with treating hyperbaric physician –likely CO toxicity Passengers constantly in touch with this MD, polysymptomatic, angry, infuriated by Co. statements n Company cannot explain incident at this time n What would you as the advising Occ Doc do ? 19

Contain and Manage the Problem n n Information session ( Q&A) for all those affected as soon as possible Employer HR, Hyperbaric Physician, Neurologist and myself present Full acknowledgement of health impact on these individuals, including the likely possibility of CO poisoning and / or other contributing factors Offer a voluntary individual neurological evaluation and review of all information relevant to the event 20

Referral Letter to the Neurologist n n Review each patient’s account of their experience in terms of ill effects and review hospital health records Review each patient’s observations while in the lifeboat enroute to the CCG vessel Initiate any appropriate medical follow-up and pursue any medical investigation as required Provide each patient with your opinion regarding the nature of their concerns, the relationship to CO and your prognosis regarding future health issues 21

Final Report from Neurologist Suggested n n 12 of 17 patients assessed, all became ill to varying degrees – vessel operators asymptomatic Illness was induced by motion sickness, nauseous fume inhalation, as well as local environmental stressors (confined space, others vomiting, etc. ) all compounded by a stressed emotional atmosphere Majority completely resolved over the coming days and weeks 2 patients : symptoms of PTSD 1 patient : STI Neck 2 patients : Iatrogenic middle ear barotrauma 22

Closing Comments from Neurology n n n Suspicion of potential carbon monoxide poisoning was correct, and hyperbaric O 2 treatment reasonable Subsequent investigation and review of all information supported a conclusion that clinically significant carbon monoxide exposure did not occur in this patient population No follow up indicated or requested by patients themselves 23

Key Points – Carbon Monoxide and Asbestos Scenarios n n n If employee population affected by acute health hazard or ongoing chronic health hazard, immediate intervention required Research topic fully and any IH information Communicate all factual information re: situation and health effects to employee group Offer individual health assessments on a compassionate / confidential basis Consider ongoing health care and health risk management as a result of exposure 24

Scenario 3 – Compassion & Communication n Transportation to and from offshore and Oil and Gas Installations in Eastern Canada The role of Atlantic Offshore Medical Services (AOMS) Offshore related disasters 25

Loss of Cougar Flight 491 – March 2009 n n 10: 20 am call from Cougar, helicopter ditching 35 miles east of St. John’s, 17 onboard 10: 30 am Operator confirmation of the incident 10: 30 am to 10: 50 am Notification Tertiary Health Care, 1 st on-call Medevac Teams, AOMS Office Physicians, EAP / Counseling services to ensure a state of readiness 11: 00 am operator call confirming involvement of AOMS employee. Fly over indicates helicopter on surface and life rafts inflated 26

In House AOMS Response n n Contain event-related information in-house; tight control of incoming media calls, etc. Management to relay accurate information inhouse as it unfolds Instances where inappropriate information was received Management team members placed on full alert 27

The Reality of the Situation – Late Afternoon n n 1 injured survivor and 1 body retrieved from the water; life rafts empty; no evidence of survivors AOMS facilitates transportation and meets next of kin on arrival in St. John’s Formal notification of next of kin and family members; designated facility / hotel setup established AOMS Management personnel support families during recurrent debriefings 28

Ensure the Integrity of AOMS Services n n Arrange alternate medevac systems on a temporary basis Individual calls to on duty and off duty offshore medics, NL and NS General staff meeting to update all on the events to date Impact on offshore helicopter travel; prepare for employee transport by vessel 29

Next of Kin Support n n Senior Physicians, HR and Management meeting with widow, parents, and family members of the AOMS medic Meeting with the AOMS Case Manager who lost her spouse Recommendation of counseling and support services to all parties, and offer of support in any which way that we could Notification of AOMS Insurers / Benefits Consultants 30

Concluding Practice Suggestions n n Formal introduction to each patient communication /compassion/containment Respect and protect the patient - treating physician relationship communication /compassion n Ensure Medical decisions /advice supportable by peer review and meet applicable legislation communication /consultation n Consult with peers and experts in Occupational Medicine as necessary communication /consultation 31

n Communicate Occupational Health Policy and Program to Management and Employee Reps prior to implementation communication /containment n Understand respect the business needs of your client but never compromise the ethics or principles of practice of Occupational Medicine communication /consultation/compassion 32