key: cord-022054-yeavs06o authors: Guidotti, Tee L. title: Occupational Medicine: An Asset in Time of Crisis date: 2009-05-15 journal: Disaster Medicine DOI: 10.1016/b978-0-323-03253-7.50030-3 sha: doc_id: 22054 cord_uid: yeavs06o nan c h a p t e r 2 3 Occupational Medicine: An Asset in Time of Crisis Corporations and other large institutions have become deeply concerned with continuity of operations and the security of their personnel. The new urgency placed on these functions since Sept. 11, 2001 , has drawn attention to a substantial resource already in place in such organizations-their occupational health services. The imperatives of corporate security and homeland defense have, in turn, invigorated and expanded the mission of occupational medicine, one of the oldest recognized medical specialties. 1 Occupational health services are most familiar in the manufacturing sector and in the setting of a plant's medical clinic. Typically, such services include at least one occupational health nurse (also a professional specialization); an occupational physician (typically on contract); and support staff, all of whom report on a regular basis to a plant manager and are responsible professionally to a corporate medical director, who himself or herself serves as a traveling troubleshooter, in-house resource on health issues, and auditor for health affairs. This physician-led, health-centered team typically is engaged in regular interaction and troubleshooting in collaboration with an industrial hygienist and safety officer, who are usually oriented more toward process and plant operations, documenting regulatory compliance, and identifying and measuring health hazards. These hazardoriented professionals usually report to a different manager or directly to the plant manager. This basic pattern was once the norm in industry, but the dramatic reorganization in industry, management focus on core business, and the rise of the service sector have forged a new pattern, in which services are outsourced to contractors and consultants. 2 However, whichever pattern is followed in a particular enterprise, the following essentials are in place in most large operations: a means of monitoring the health of workers, a system for documenting their health, a system for documenting and evaluating hazards, a mechanism for responding to emergencies, and a panel of health consultants. 3 This is exactly the type of infrastructure that large organizations need so that they can respond to disasters and protect the security and continuity of operations. 4 Thus, large organizations already have in place a structure on which to build to protect their operations and personnel. Involvement of the occupational health service in emergency management, which was common in the past, is a natural extension into disaster medicine, involving training and preparation for consequence management and mitigation activities, 5 preparedness for a response indigenous to the physical plant, and planning for the management of risks inherent to the operation. 2, 6 The occupational health service also has an important place at the table as an active member of the healthcare team, interacting with local prehospital care providers and hospitals on the Local Emergency Preparedness Committee (LEPC). Box 23-1 presents the usual functions of a corporate medical department, provided or supervised by occupational physicians. 2 These functions have traditionally been clustered in a few broad missions: to protect health, to support productivity, to reduce loss and liability, to manage health affairs, and to ensure compliance with regulations and best practice for the industry. These functions have traditionally been viewed as support functions, not part of the business operations of the organization. Indeed, this is why these functions were subject to outsourcing throughout the private and government sectors during the 1980s and 1990s. A new realization of the criticality of these functions is spreading in the corporate sector, stirred by the awareness of the profound threat of major industrial incidents and potential terrorist attacks to the continuity of operations and the survival of key personnel. 4, 7 The role of the occupational physician is increasingly recognized for its potential to contribute to the survival of the enterprise, not just its efficient operation. 3 For example, Dow received an award from the state of Michigan Public Health Department for assistance to the state, particularly with respect to its efforts in disaster planning. The usefulness of a trained, well-informed, prequalified medical resource for dealing with incidents on-site is obvious. These incidents may include, but are certainly not limited to, sending infectious material through the mail to company personnel and using company equipment, such as airplanes or, potentially, chemical plants or storage facilities, as instruments of assault. The occupational physician, who is trained in hazard assessment, also may assume the responsibility of determining when a site is safe to re-enter or when a facility can be reopened. He or she also would be responsible for managing the psychological consequences of an assault. Less obvious, but equally valuable, is the role that such physicians may play in managing the consequences of widespread disruption to business operations due to major threats and in protecting the business, the product, and the brand against catastrophe in cases in which a company's products, facilities, or operations are used to deliver a threat or become targets for terrorist activity. In time of crisis, the occupational physician may help get the community back on its feet by helping to keep an employer open or critical infrastructure functioning. 8 Similarly, the occupational physician has been called on to manage the corporate response to serious health-related issues, such as traveling to areas in which severe acute respiratory syndrome (SARS) and other emerging infections are a risk; rapidly investigating suspicious outbreaks of disease or exposure to potential hazards; and determining when re-entry and reoccupancy is possible in contaminated facilities, such as post office facilities contaminated with anthrax. 4 Several companies, including Cathay Pacific, participated in an informal monitoring network during the SARS epidemic to share observed trends and experience when the information they needed was not forthcoming from conventional sources. Procter and Gamble, alerted to the emerging problem by its own corporate medical leader for China, instituted SARS precautions a month before any official warnings were advised. These functions build on the traditional involvement of physicians in disaster planning, as well as health protection for employees. 2, 6 Disaster planning has traditionally been one of the core functions of the medical department and occupational physicians in corporate settings. The physician has usually assumed responsibility within the organization for planning the medical response to emergencies, identifying facilities and resources for dealing with serious injuries and mass casualties, and providing health protection for key personnel, if required. Although outsourcing has reduced the direct involvement of occupational physicians in planning emergency management in many organizations, particularly in the service sector, this function has not been completely replaced by external consultants because it requires a practitioner with intimate knowledge of the operations, hazards, workforce, and policies of the organization. The occupational physician can add value to the management of catastrophic consequences in many other ways. These include the following: • Survival of key personnel in a catastrophic event • Continuity of business after a catastrophic event • Instant connectivity to resources for assistance in a health-related emergency • Surveillance of the workforce and the early detection of an outbreak • Integration of emergency response with public health agencies • Surge capacity in the event of a local event that requires mobilization of all available medical resources • Vaccination programs and other protective measures • Establishing on-site consequence management and mitigation programs • Developing decontamination plans • Providing specialized, sector-specific expertise to emergency managers • Advising on effective personal protective equipment (PPE) • Liasing with the LEPC, prehospital care, and hospitals • Continuing education and training on-site and in the community of the indigenous risks inherent to the operation • Accessing material safety data sheet information • Leading any after-action discussion to bring about process and system improvement • Fitness-to-work evaluations that assess the recovery and functional capacity of injured employees to return to work and what accommodations may be needed • Impairment evaluation for injured workers who are the subject of workers' compensation claims • Certification of time off work for workers with a nonoccupational illness or injury (this is often performed by other physicians) 4. Review of workers' compensation claims for causation 5. Periodic health surveillance of employees exposed to a particular hazard, such as noise, chemicals, dusts, or radiation (this often takes the form of a medical examination, often conducted annually) 6. Investigation of exceptional hazards, disease outbreaks, unusual injuries, fatalities, or other emerging issues 7. Prevention, health promotion, and educational programs designed to enhance the health of employees and to increase productivity 8. Management of the health problems of employees on-site to reduce absence and disability 9. Advice and consultation to management on issues of health, health and workers' compensation insurance, and regulatory issues in occupational health 10. Disaster planning and emergency management on-site 11. External communications on health issues (e.g., with local public health agencies and local physicians) 12. Managing relations between the organization and local hospitals and the medical community 13. Employee assistance programs for employees with problems involving alcohol and drug abuse or other addictive behaviors, such as gambling, that interfere with work 14. Executive wellness programs, such as special medical evaluations or monitoring health problems among senior executives Larger and more complex organizations may also involve the occupational physician in managing environmental risks, product safety, contracting for health services, representing the organization in industry-wide health activities, and proactive programs for preparedness, risk management, and other senior management functions. Performing these duties effectively requires committed time for preparedness activities and an occupational health service that is structured and whose providers are trained to play such a role in time of crisis. However, it is costly and inefficient for even large corporations to dedicate a full staff and support structure for the management of an event that may or may not materialize. This is why adaptation of the existing occupational health service makes sense for many employers, especially those in critical or hazardous industries. Incorporating emergency management into the mission of the occupational health service builds allows for an emergency response system that a business would not otherwise have. The same resources used for tracking employees' health can be used for surveillance to detect potential disease outbreaks due to bioterrorism. The technology of hazard identification and measurement can be applied to detect chemical or radiation threats. The medical staff on duty primarily to monitor health and to provide timely clinical care can provide surge capacity in time of crisis. Health protection for senior executives, and the personal knowledge that this entails, can keep key personnel on the job and safe, especially when they are moved to new locations or are operating under conditions of stress and potential risk. The skills that are normally applied to ensuring a safe workplace can be used to determine when it is acceptable to return to work or to venture into a facility that has been contaminated or damaged. Planning for foreseeable industrial disasters can inform and refine the response to unforeseen threats, given that sophisticated disaster planning is a matter of identifying resources and contingencies, not deriving detailed plans for single-threat incidents. Perhaps most attractive to cost-conscious managers is that investment in expanding the emergency management capacity within an occupational health service is not "lost" if an event never occurs. The same capacity supports and enhances the traditional occupational health services that industry and government employees require and may lead to cost savings, increased productivity, and reduced liability in their own right. Occupational physicians, who are conscious of their responsibility and aware of their own position on the firing line along with the employees and executives they protect, have been preparing themselves for an expanded role in emergency management. The principal specialty organization, the American College of Occupational and Environmental Medicine (ACOEM), has for some time offered training in the characteristics of weapons of mass destruction (well before Sept. 11, 2001 , and the anthrax assaults), emerging infections (particularly using the model of SARS), and "tabletop" exercises to train participants in emergency management and consequence management for disasters and mass casualties. Immediately after the Sept. 11, 2001, tragedy, an ACOEM task force produced a guide to the management of mental health issues among survivors of mass assaults, disseminated it to all members, and posted it on the ACOEM Web site-all within four days. This achievement was unique and widely admired among medical specialty organizations. In 2003, leaders within ACEOEM developed the Occupational Health Coordinating Group (OH-CG) as a resource for coordinating responses, accessing management resources, and sharing information in times of crisis. It includes physicians, occupational health nurses, industrial hygienists, and other occupational health professionals. The OH-CG is a working council, sponsored by the Department of Health and Human Services, within what will eventually become a health-sector ISAC (Informational Sharing and Coordination) organization. This is a highly unusual and encouraging development in many respects. ISACs have official status with the Department of Homeland Security and are intended to coordinate the planning response of critical sectors of the American economy and society. They have been formed, for example, in industry sectors such as critical utilities and transportation. The OH-CG was the first health-sector ISAC to be created and is now the Occupational Health Subcommittee of the Healthcare Sector Coordinating Council, the ISAC for healthcare. This is a remarkable achievement for a relatively small medical specialty. Because occupational health is crosscutting across industries, the OH-CG is expected to serve as a resource for other critical sectors rather than to focus primarily on the health sector per se and in so doing uniquely relate to other ISACs as much as the one of which it is a part. Its mission is to provide occupational health professionals with what they need and when they need it in a time of crisis through channels that do not depend on any one mode of communication. How might an organization prepare its occupational health department to respond on this scale in a crisis? Partly, the answer is to build an effective and efficient team. Teamwork comes from training and planning but also from regular personal contact and cooperation. A team that functions well in the complex duties of an occupational health service and that already knows the operations, workforce, and facilities is more likely to function well in an emergency than would an outside provider, who may not be around during a crisis. Another part of the answer is to build redundant information and communication systems that can quickly retrieve critical information on hazards, disease or injury patterns, and individual health records in an adverse environment. Occupational health systems may require upgrading to do this effectively, but the technology is readily available. Partnerships within the LEPC, local industry, and other like facilities not only reduce the initial and ongoing costs but also enable more efficient planning, training, and response. Acquiring the necessary expertise is obvious. The occupational health staff may require special training to take on the additional functions, but this is not much of a stretch from current duties. County emergency managers are eager to share training opportunities through grants and other programs within the public domain. On-site training and response in coordination with local prehospital care using strategies of consequence management and mitigation, education, decontamination, and PPE will support Occupational Safety and Health Administration efforts to protect workers and may reduce liability exposure for the organization's insurers. The expense for pre-paredness may be justified by potential reductions in insurance premiums, as well as reduction of loss in the event of an emergency. Establishing networks and agreements for mutual assistance may be critical. Here, the occupational health staff can coordinate arrangements with local hospitals, specialist practitioners, public health agencies, and first responders in advance and maintain personal relationships required for smooth operation in the event of a crisis. The first step is to forge an active participant's role in the LEPC. Some counties have a more active, dynamic, and responsive LEPC than others do. An occupational health service for a large organization has the opportunity to lead and become the backbone of emergency management in the community. Facilities planning may be required, taking into account the characteristics of the site for evacuation, securing the premises but preserving access for ambulances and first responders, and defining areas of the plant for operational response (e.g., for staging rescue operations, triage, stabilizing casualties, decontamination, and "incident command" 9 activities). Even locations without special hazards may benefit from such contingency planning in the event of an external threat. For example, the first anthrax assault was in the office of a newspaper, not normally a high-risk location. Under various contingencies, surge capacity may be projected, as well as whether to call in help for managing mass casualties on-site (especially if local hospitals are not functioning or cannot be reached), to assist other units in a mutual assistance pact, or to perform services such as mass immunizations. On-site decontamination may have to be continued at the hospital or a second location away from the industrial incident. Surge capacity operations may be created away from the hospital under the direction of the LEPC, county emergency manager, or hospital. This may include separate healthcare mutual aid agreements specific for the incident and secondary triage and treatment provided by trained physicians and other healthcare providers through the use of vendor agreements or prepositioned equipment and supplies. This strategy will enable the hospital and community healthcare delivery system to operate at near-standard operations during an industrial incident. Any facility that has potable water, electricity, and shelter may participate. Pre-existing arrangements for accessing these sites should be spelled out under mutual aid agreements, vendor contracts, memoranda of understanding, or special circumstances agreements negotiated in advance between the county emergency management office, the hospital, or the local employer. Documentation of expenditures is a critical function, just as it is in the incident command structure, 9 to reimburse all nonvolunteers and contracts executed in the response. Certain routine functions can be anticipated and planned. For example, if anthrax or some other threat is determined to be a possibility for a business, procedures can be put in place in advance to protect employees, limit disruption, and rapidly evaluate evolving situations. This was done in a timely manner by DST Output, the nation's largest direct mail operation, on the advice of its medical director. Planning is particularly important to deter inevitable hoaxes and to prevent disruptions to business from ill-defined or unknown hazards. For example, the common scenario of an unknown "white powder" appearing on a loading dock or in an office can shut down operations for a day or more until a toxic substance is ruled out. Having the capacity on hand to show that it is harmless saves time and anxiety. Confronted with a true emergency, most people behave in an adaptive, rational manner that helps them to get through the crisis and to mitigate personal damage or injury. Some are capable of helping others in an emergency. 10 This response appears to be shaped, at least in part, by whether the emergency arises from a natural disaster or a "technological" event (an incident arising from human agency). 6 The perception of an intentional assault may also shape the psychological response for some people. Some people in situations of perceived catastrophic risk behave irrationally, however, and demonstrate psychogenic symptoms and maladaptive behavior. [11] [12] [13] [14] [15] [16] [17] [18] [19] [20] [21] [22] Dealing with anxiety-promoting perceptions and psychogenic symptoms among employees that arise from rumors or incidental illness occurring at the worksite requires skill in rapid assessment and in risk communication but can save an enterprise from devastating loss of confidence and potential loss from employees who may refuse to come to work. Distinguishing between human drama and a true emergency arising from a nonobvious cause is also a challenge that requires specialized expertise that is within the scope of the occupational physician. An enterprise may be in a position to control its liability and potential loss from claims after a disaster by developing a flexible, effective emergency management capability within its occupational health services before a disaster event. In addition to reducing actual loss through planning and effective consequence management, which is most important, such an enterprise would also be able to show after the fact that it had done its due diligence in anticipating and preparing for plausible threats. This could reduce its exposure to punitive awards or claims based on negligence or omission. Legal opinions on this may vary, but it seems reasonable that a company that appears to be prepared is less likely to be accused after the fact of ignoring a foreseeable threat. In the classic business model followed during times of business as usual, the priorities of corporate management in descending order are shareholder value and profitability, continuity of production and operations, and loss control and risk management. For government agencies, there is a similar set of priorities, with the mission of the agency coming first. However, in times of crisis, survival of the enterprise and protection of people take precedence. In the past, occupational medicine and occupational health services have always been perceived as support functions, facilitating management priorities, but not core business priorities. In the new era of threats to survival and business continuity, occupational health services and the physicians in them may play a role in the survival of the enterprise and its people. A wise organization, faced with an extraordinary threat, may look within to build its salvation on a functioning system that already serves its interests. What is the strategic value of occupational and environmental medicine? 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