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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 Asthma


Salmon Processing
Laggan Dam    Lochaber Aluminium Smelter




Power 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 affect
their 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
        Aquaculture
Machinery, weather, lone working
Disease in the stock and their
  treatments
Pesticides
Inhalation of particles
Economic pressure of the market
Occupational Health in
     Salmon Farming and Processing




2000 rural jobs in Scotland   Multi national industry
concern for the environment   Norway , Chile,
                              Canada, Tasmania
Hard work on a fish farm
Sea Lice and Furunculosis
Where does the pesticide go?




Acute and Chronic OP poisoning evidence and opinion
Fish Farmers PPE for
  Organophoshates
Salmon Immunisation
to prevent Furunculosis
Aeromonas Salmonitica
Needle-stick injury from
  oil based vaccine
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
Salmon processing causing
   occupational asthma
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 SAFETY
10-12 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 Club




30 meters depth , cold water, nitrogen narcosis , tides ,boat cover
- training and dive planning for safety
Heat Loss and Hypothermia
Descent Phase of Dive
Ascent phase of Dive

Cerebral 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 dive
Acute Spinal Decompression Sickness
Physical Signs in
Neurological Decompression Sickness Affecting Spinal Cord


   Girdle pain
   Motor and proprioception deficit
   Urinary retention
   Evolving multi site spinal haemorraghe
   Minutes matter!
   Entirely a clinical diagnosis
   – don't 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!

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Occupational health in rural general practice 2011

  • 1. Occupational Health in Rural General Practice Dr James Douglas, Tweeddale Medical Practice, Fort William, Scotland.UK
  • 2. Occupational Health in Rural Practice • Agriculture • Aquaculture • Food processing • Forestry • Tourism • Outdoor Education • Diving • NHS/ Local Government / Utilities
  • 3. Occupational Health as a GP in Fort William Fish Farming Diving Medicine Research Occupational Asthma Salmon Processing
  • 4. Laggan Dam Lochaber Aluminium Smelter Power House Cell Room
  • 5. 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?
  • 6. 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
  • 7. 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
  • 8. 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
  • 9. Will this patients illness affect their 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
  • 11. Occupational Health in Agriculture and Aquaculture Machinery, weather, lone working Disease in the stock and their treatments Pesticides Inhalation of particles Economic pressure of the market
  • 12. Occupational Health in Salmon Farming and Processing 2000 rural jobs in Scotland Multi national industry concern for the environment Norway , Chile, Canada, Tasmania
  • 13. Hard work on a fish farm
  • 14. Sea Lice and Furunculosis
  • 15. Where does the pesticide go? Acute and Chronic OP poisoning evidence and opinion
  • 16. Fish Farmers PPE for Organophoshates
  • 17. Salmon Immunisation to prevent Furunculosis Aeromonas Salmonitica
  • 18. Needle-stick injury from oil based vaccine
  • 19. 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
  • 20. Salmon processing causing occupational asthma
  • 21. 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
  • 22. 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!
  • 23. 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
  • 24. 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!
  • 25. SPORT DIVING and DIVING SAFETY 10-12 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
  • 26. Sport Diving on Thesis Wreck Sound of Mull with Scottish Sub Aqua Club 30 meters depth , cold water, nitrogen narcosis , tides ,boat cover - training and dive planning for safety
  • 27. Heat Loss and Hypothermia
  • 29. Ascent phase of Dive Cerebral Arterial Gas Embolism
  • 30. Ascent phase of dive Pulmonary Barotrauma • Interstital Emphysema • Pneumothorax • Underwater blast injury • Training • Medical Screening
  • 31. 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
  • 32. 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
  • 33. Ascent phase of dive Acute Spinal Decompression Sickness
  • 34. Physical Signs in Neurological Decompression Sickness Affecting Spinal Cord Girdle pain Motor and proprioception deficit Urinary retention Evolving multi site spinal haemorraghe Minutes matter! Entirely a clinical diagnosis – don't delay with scans in A&E
  • 35. Treatment of Acute Decompression sickness Breathing 100% O2 for periods at depth
  • 36. 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
  • 37. 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!