Problem-Solving Techniques in Occupational Medicine Dennis Shusterman, MD, MPH Sebastopol, California The diagnosis of occupational illnesses may be considerably more difficult than is the case with occupational injuries be­ cause of a variety of factors: an intervening latency period, uncertainty in identifying the most significant chemical or physical exposures, determination of exposure levels retro­ spectively, and coordination of the physician with regulatory and workers' compensation bureaucracies. Such problem­ solving techniques as retrospective industrial hygiene and at­ tention to in-situ chemistry can act as means of reducing the uncertainty in making the diagnosis of occupational illness. Advance familiarity with workers’ compensation and state or federal regulatory agencies can further facilitate diagnosis and patient advocacy. Few areas of medicine so thoroughly challenge regulatory agencies, and state workers’ compensa­ the family physician’s technical and organizational tion systems all present barriers to successful skills as the realm of occupational injuries and diagnosis and patient advocacy in the field of oc­ illnesses. Based upon survey data, the Bureau of cupational medicine. A number of excellent arti­ Labor Statistics of the US Department of Labor cles have appeared in the primary care literature estimates that some five million occupational emphasizing occupational history-taking and in­ cases occur each year nationally, of which 2 to 3 formation resources.2 7 The aim of this article is to percent qualify as “occupational illnesses,” ie, re­ highlight problem-solving techniques in the con­ sponses to noxious physical, chemical, or biologi­ text of brief case histories. cal agents in the workplace.1 Facility in obtaining a detailed occupational history, access to informa­ tion resources regarding toxicology, and finally, Illustrative Cases the interface with industrial hygiene personnel, Case 1 A 40-year-old, female, electronics worker was From the Department of Family and Community Medicine, evaluated after having been examined and ob­ School of Medicine, University of California, San Francisco, served overnight in an emergency room for the San Francisco, California. Requests for reprints should be addressed to Dr. Dennis Shusterman, PO Box 1149, Sebas­ effects of an acute overexposure to phosphine gas topol, CA 95472. (PH3), used in semiconductor fabrication. While e 1985 Appleton-Century-Crofts the JOURNAL OF FAMILY PRACTICE, VOL. 21, NO. 3: 195-199, 1985 195 OCCUPATIONAL MEDICINE this agent is capable of producing pneumonitis and were exceeded on more than one occasion. More noncardiogenic pulmonary edema in sufficient importantly, since the previously tolerated odor of concentrations,8 in this case the symptoms of phosphine was now associated by the patient with lightheadedness and dyspnea were not accom­ an episode of intense respiratory irritation, it was panied by any radiographic or electrocardio­ fair to state that she was psychologically sen­ graphic changes, and arterial blood gases showed sitized to her work environment. Barring indus­ only a mild respiratory alkalosis without trial hygiene measures sufficient to control phos­ hypoxemia. The patient was a nonsmoker with no phine concentrations below the odor threshold, identified chronic health problems, and abnor­ she could not remain in the work environment malities on physical examination in the emergency without experiencing episodes of hypervenilation. room were confined to an apparent chemical con­ Reassignment was obtained with no recurrence of junctivitis. symptoms. On reevaluation four months later, the patient reported having had mild exertional dyspnea and wheezing away from the workplace, which had largely resolved. More significantly, she com­ Comment plained of symptoms consistent with hyperventi­ Attempts to reconstruct workplace conditions lation when she smelled the characteristic garlic­ based on historical factors (such as the perception like odor of phosphine that occurred transiently on of an odor) or on biological monitoring (such as the job, an odor she had previously tolerated be­ blood levels of a toxin) might be termed retro­ fore her overexposure. Use of an aerosol bron- spective industrial hygiene. While not identical to chodilator in the interval since her emergency workplace air sampling, these techniques do have room visit helped with her apparent transient specific reference to the actual exposure condi­ bronchial hyperreactivity, but did not control her tions that pertained during a particular time frame. work-related symptoms. In her own words, she (For some exposures, such as lead, both industrial felt “paranoid” about her work environment and hygiene and biological monioring may be required desired reassignment or job retraining. by standards.) A workplace inspection, by con­ Physical examination revealed a relaxed woman trast, may or may not document representative with a resting respiratory rate of 20 per minute, conditions, depending on a variety of factors, in­ chest clear to auscultation, no peripheral cyanosis cluding the specific circumstances of an acute or clubbing, and no murmur or gallop on cardiac overexposure and the degree to which the work examination. Pulmonary function testing showed environment has been modified in anticipation of only minimal reversible airflow obstruction the inspection. The following case illustrates this (forced expiratory volume in one second was factor. 2.0 L, or 83 percent of predicted, rising to 2.58 L, or 107 percent, after bronchodilators), with normal lung volumes, arterial blood gases, and carbon monoxide diffusion capacity. No bronchial Case 2 provocation testing was done, as phosphine acts A 32-year-old automobile mechanic presented as an irritant rather than an allergen and is capable to his family physician with the complaint of head­ of producing tracheitis and bronchospasm in es­ aches that were global in location, daily in occur­ sentially any individual.9 rence, and not associated with visual auras, While industrial hygiene measurements of the nausea, localized weakness, or sensory distur­ patient’s work environment were not available, in­ bance. He was a nonsmoker and denied any his­ formation on the odor threshold for phosphine, tory of sinusitis or allergies. He did feel that this variously reported as 0.02 to 3.0 ppm,9’10 raised the problem was associated with the institution one possibility that both the existing Occupational month earlier of several heat-conserving measures Safety and Health Administration (OSHA) stand­ in his workplace at the beginning of the cold wea­ ard for an average exposure of 0.2 ppm and a rec­ ther season. These measures included keeping the ommended short-term exposure limit of 1 ppm11 garage doors partially or completely closed (even 196 THE JOURNAL OF FAMILY PRACTICE, VOL. 21, NO. 3, 1985 OCCUPATIONAL MEDICINE when cars were running), placing plastic trash consequence of an exposure outside of the bags over the roof vents, and using an unvented, workplace, the patient would have had to come to catalytic kerosene heater indoors. He had been off work with a carboxyhemoglobin level four times work for several days at the time of the first visit, that, or 68 percent. With the range for production and while there had been some improvement in his of a state of coma being 38 to 60 percent,9 this was symptoms, he still complained of occipital head­ unlikely to have been the sequence of events. The aches. workers' compensation insurance carrier appar­ The patient had borderline hypertension (140/90 ently agreed, and temporary disability was granted mmHg), and there were normal findings on car­ without adjudication. diopulmonary, neurological, and fundoscopic exam­ ination. Musculoskeletal examination revealed moderate occipital and trapezius muscle group tenderness. A baseline carboxyhemoglobin level Comment was obtained and was reported as “ undetecta­ Workers’ compensation, as it is variously im­ ble—less than 5 percent.” The patient was plemented by individual states, is a no-fault insur­ prescribed a muscle relaxant and mild analgesic, ance system that generally compensates for and he was instructed to return to work and to work-related health problems without regard to report for another carboxyhemoglobin determina­ culpability, relieving workers from the compen­ tion at the close of his second day back at work. satory exclusion of “ contributory negligence” as On follow-up, the patient reported a good thera­ well as protecting the employer from lawsuit in peutic response only until he had been back in the most cases (“ exclusive remedy”). The principal workplace for a few hours, after which time his built-in incentive is for the employer to maintain a headache recurred. The diagnosis was made of favorable claims record in order to keep premiums headaches secondary to carbon monoxide intoxi­ down. To this end, most workers’ compensation cation when the second carboxyhemoglobin level insurance carriers employ their own industrial was reported to be 17 percent. The presumed hygienists and safety personnel who can consult in mechanism of temporal generalization of these their clients’ workplaces. headaches was via occipital muscle spasm. The vast majority of employers comprehend the The patient was advised of his options under the indirect nature of the system and are able to learn California Occupational Health and Safety Admin­ from a claims experience, even if the lesson is only istration of filing an anonymous