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Occupational health
Although this is strictly speaking a public health field, a considerable number of patients come to the attention of internal medicine when they have readily identifiable illness related to work, or more confusingly, when there seems to be an association between the illness and the work, but nobody seems to be quite sure what it is.
Assume the association is real until you have evidence to suggest that it isn’t.
Most occupational diseases are associated with long-term exposure but there are instances where short sharp exposure can cause considerable disability – e.g. so-called ‘acute’ silicosis.
With reversible illnesses, the first principle should be to try to secure alternative employment within a company rather than to just seek compensation, as settlements are often small compared to the security of long term employment.
Enter into communication with employers early, usually with a letter asking about details of duration of employment and type of exposure. Phrase this as an aid to a problem solving exercise – you are first interested in determining what is wrong with the patient. Most employers are all too aware of the legal minefield that compensation entails, and are willing to assist with the potential return to health of what may well be a valuable employee. The recalcitrant employers are quickly obvious, so there is no need to start off on an acrimonious footing.
Sorting out occupational issues is time consuming – prepare the patient for the fact that things may drag on for quite a bit, and prepare yourself for quite a lot of writing.
Interstitial lung disease and pneumoconioses
Silicosis can be due to industrial dust exposure (mining, sandblasting, brick making and some foundry work) but is also seen in women who grind corn at home using a stone pestle and mortar. Clinical features are worsening shortness of breath and a dry cough without crackles or clubbing. It can progress to cor pulmonale. The CXR shows middle and upper zone nodularity with fibrosis, with basal Kerley Bs and pleural thickening. Eggshell (peripheral) calcification of hilar nodes is highly suggestive. In the absence of the eggshell calcification, such a CXR is almost invariably but incorrectly labelled as showing ‘old tuberculosis’. There is an association with later development of tuberculosis, however, and such patients are also more likely to develop a pneumothorax. There is also a weak association with systemic sclerosis. Management is prevention of further exposure, but there is unlikely to be any reversibility.
Asbestosis
is associated with all types of asbestos, although crocidolite is the most dangerous. Exposure from mining is usually easily identifiable on history, but exposure in other industries is less obvious: brake lining manufacture, insulation and so-called asbestos-cement products. Although new exposure should almost have ceased now, there is still a pool of patients exposed some decades ago. Patients develop shortness of breath, basal and axillary crackles, and clubbing. The CXR shows basal linear shadowing. Once calcified pleural plaques are visible the diagnosis is usually fairly clear.
Mesothelioma.
This is also associated with asbestos exposure and is compensable. Diagnosis is usually by pleural biopsy.
Byssinosis.
This illness is characterised by shortness of breath associated with returning to work at the beginning of the week. The spectrum extends from symptoms and no signs to a full set of features suggestive of extrinsic allergic alveolitis (dry cough and wheeze). It is still unclear if this syndrome can lead to permanent disability independent of concurrent cigarette smoking.
Occupational asthma
Occupational asthma is suspected from a history of worsening of symptoms in the work environment, and relief over holidays and weekends. Common allergens include flour and some industrial solvents such as thiocyanates and the very volatile paints used in the motorcar spraying industry. Management issues revolve around trying to secure alternative work in a non-allergenic environment.
Compensation claims
Ideally, this should be done by company doctors employed for this purpose, so always check first that you aren’t duplicating work. The patient may be frustrated by the slow process and may be trying a different route. Many claims take from six months to a couple of years to sort out.
Is it plausible that the patient’s disability is due to occupational exposure?
Firm up the history of exposure by getting details of employment record (e.g. old pay slips) and quantify the degree of disability or illness (e.g. silicosis with FEV1 of 1.2, FVC 1.6, or mesothelioma confirmed histologically, etc)
Obtain from the Occupational Health Dept the correct ‘first assessment’ forms and fill them in.
Send them off with all supporting documents and X-Rays (make copies first!)
When requested, fill in the second set of forms.