Occupational Health in Rural General Practice Dr James Douglas, Tweeddale Medical Practice, Fort William, Scotland.UK
Occupational Health in Rural Practice• Agriculture• Aquaculture• Food processing• Forestry• Tourism• Outdoor Education• Diving• NHS/ Local Government / Utilities
Occupational Health as a GP in Fort William Fish Farming Diving Medicine Research Occupational AsthmaSalmon Processing
Laggan Dam Lochaber Aluminium SmelterPower House Cell Room
Principles of Occupational Health• Is this illness or symptom caused or aggravated by the job?• Will this patients illness affect their job and the safety of others?
Is this illness or symptom caused or aggravated by the job?• Occupational asthma / dermatitis• Occupational Deafness / Vibration Illness• Musculoskeletal Injury• Bladder Cancer / Mesotheiloma• Poisoning – lead, CO,methane,H2S• Zoonosis in rural populations• Infection in NHS
Will this patients illness affect their job or the safety of others at Alcan?• Hot Metal Work – heat stress and unexpected incapacity• Pot Room Asthma – Hydrogen Fluoride
Will this patients illness affect their job or the safety of others at Alcan?• Hydro and Estates – lone working and remote accidents• COMAH designation and local community safety
Will this patients illness affecttheir job or the safety of others? Clinical work done by all GPs• Unfit to work – med 3 certificate• Return to work – ? phased return plan• Chronic Disease Management – keeping the population at work and in health• Risk assessment of medication or illness - likelihood and consequence• DVLA HGV/PSV medical standards
Occupational Health Information www.hse.gov.uk
Occupational Health in Agriculture and AquacultureMachinery, weather, lone workingDisease in the stock and their treatmentsPesticidesInhalation of particlesEconomic pressure of the market
Occupational Health in Salmon Farming and Processing2000 rural jobs in Scotland Multi national industryconcern for the environment Norway , Chile, Canada, Tasmania
Rural GP and their community• Visibility , geographically defined population• “ BA chest” in Inverlochy 1980s as a young GP• COPD in short retirement• Sheep Dip in crofters and neurological effects• Previous recession and new industry for rural Scotland – salmon farming and processing
Occupational Asthma clinical history• Asthma caused or aggravated by work• Symptom patterns vary with work in the early stages• 2 weeks to 6 months onset• Early diagnosis essential for individual and whole workforce• Chronic phase diagnosis difficult
RESEARCH METHODOLOGY• CROSS SECTIONAL SURVEY to identify cases against a diagnostic standard• CASE CONTROL STUDY to determine why patients get the disease• Compare and contrast cases and “non cases” ( controls from the same factory)• Smoking / Atopy / Place of work/ Age /sex• Has engineering modification worked?• The company still need to process and sell fish!
Why the GP ? surely this is a specialist area and covered by too much Health and Safety activity already!• Local knowledge of patients and work• No chance in diagnosis without the GP being open to the diagnosis• Interesting and about simple clinical care of patients
Sport Diving in UK• British Sub Aqua Club , Scottish Sub Aqua Club, PADI worldwide franchise.• Some Sport Diving Instructors can be classed as professional divers by HSE• Underwater Archaeology and Scientific Diving has its roots and training systems from sport diving but classed as professional• Clam divers on the margins!
SPORT DIVING and DIVING SAFETY10-12 UK fatalities per year , 50 episodes of decompression illness Diving in pairs for rescue Training with increasing challenge from shore dives to wreck diving in Scapa or West Coast - SSAC or BSAC club systems best for safety
Sport Diving on Thesis Wreck Sound of Mull with Scottish Sub Aqua Club30 meters depth , cold water, nitrogen narcosis , tides ,boat cover- training and dive planning for safety
Ascent phase of DiveCerebral Arterial Gas Embolism
Ascent phase of dive Pulmonary Barotrauma• Interstital Emphysema• Pneumothorax• Underwater blast injury• Training• Medical Screening
Ascent phase of dive Decompression Sickness Type 1&2 Acute Decompression Illness• Dissolved nitrogen comes out of solution during ascent after single or multiple long ( > 30 minutes) deep dives ( >25 metres) causing bubbles in the blood and CNS ”the bends” Lemonade analogy for the bends
Ascent phase of dive Acute decompression Illness “The bends”• An acute neurological emergency – the spinal cord and brain are at risk of permanent damage• Multilevel spinal cord motor and sensory signs – cant walk or balance• 100% Oxygen and transport to chamber by road or helicopter after discussion with recompression chamber Diver decompressing in water using wrist computer
Ascent phase of diveAcute Spinal Decompression Sickness
Physical Signs inNeurological Decompression Sickness Affecting Spinal Cord Girdle pain Motor and proprioception deficit Urinary retention Evolving multi site spinal haemorraghe Minutes matter! Entirely a clinical diagnosis – dont delay with scans in A&E
Treatment of Acute Decompression sickness Breathing 100% O2 for periods at depth
The diving emergency• Accurate history of depth, times and pattern of collapse post dive helps decide bends or barotraumas for treatment plan.• On scene - give 100% oxygen, oral fluids, aspirin, exclude rare pneumothorax• “999 Coastguard” - for evacuation and communication• Aberdeen Royal Infirmary –01224 681818 ask for Duty Diving Physician for advice
Summary of Occupational Health in Rural Practice• Care of a community• Visibility of new things and problems eg John MacDonald and tagging calves Iain MacNicol and Glensanda• You are likely to be the only person with knowledge skill and insight• Rare diagnosis• Just do it and be confident in yourself!