OCCUPATIONAL SAFETY AND HEALTH SYMPOSIA, 1976
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National Technical Information Service
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MM UNITY HEALTH CEIL
Occupational Safety and
Health Symposia, 1976
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National Inst for Occupational Safety & Health, Cincinnati, ' .
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Prepared for
American Medical Association, Chicago, 111
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Jul 77
PB 274 716
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OCCUPATIONAL SAFETY
AND HEALTH SYMPOSIA
1976
RFPRODUCFO BY
NATIONAL TECHNICAL
information SERVICE
U.S. DEPARTMENT OF COMMERCE
SPRINGFIELD. VA. 22161
U. S. DEPARTMENT OF HEALTH, EDUCATION, AND
WELFARE
Public Health Service
Center for Disease Control
National Institute for Occupational Safety and Health
1
BIBLIOGRAPHIC DATA
SHEET___________
2.
1. Report No.
3.?l\ecipi^nt’< Accession ■No./'
1 o
rt
NIOSH-77-179
5. Report Date
4. Title and Subtitle
OCCUPATIONAL SAFETY AND HEaLTH SYMPOSIA
- 1976 -
July 1977
6.
7. Auchor(s)
8. Performing Organization ReptNo.
9. Performing Organization Name and Address
10. Project/Task/U'ork Unit No.
National Institute for Occupational Safety and Health
4676 Columbia Parkway
Cincinnati, Ohio
11. Contract/Grant No.
CDC-210-76-0118
13. Type of Report & Period
Covered
12. Sponsoring Organization Name and Address
Same as above
14.
15. Supplementary Notes
16. Abstracts
The third volume of the Occupational Safety and Health Symposia is a continuing pro
duct of cooperation between NIOSH and the American Medical Association aimed at deve
loping information to assist private practitioners with part-time occupational medi
cine responsibilities. The volume consists of papers presented at the NIOSH co-spon
sored 36th AMA Congress on Occupational Health Conducted at Rochester, N.Y in Sep
tember 1976, and is published by NIOSH. The Symposium topics were medical roles in
worker’s compensation; what every physician should know about radiation; medical
recordkeeping and surveillance; interdisciplinary teamwork in the health/safety pro
fessions; medical relationships with unions and management; when workers fly; how to
do a walk-through survey; and women at work.
17. Key Uords and Document Analysis.
T
17a. Descriptors
Industrial-medicine
Ionizing radiation
Electromagnetic radiation
Preventive medicine
Medical services
Environmental surveys
Aerospace medicine
Aviation personnel
17b. Ider.tifiers/Open-Ended Terms
Sex factors
06 /J
17c. COSAT! Field 'Group
18. Availability Statement
Release unlimited
FORM NTI5-3J IPE*. IO-ya>
ENDORSED BY ANSI AND UNESW. ,
I
19. Security Cla
(This
Report)
UNCLASSIFIED
iO. Security Class ( 1 hi->
Page
________________ UNCLASSIFIED
THIS FORM MAY BE Ri.P ROIMJC ED
21. No. of Pages
22. Price fk
________
USCOMM.OC
ff
F“‘
OCCUPATIONAL SAFETY AND
dTALTH SYMPOSIA
1976
• b ?
!
U.S. DEPARTMENT OF HEALTH. EDUCATION. AND WELFARE
Public Health Service
Center for Disease Control
National Institute for Occupational Safety and Health
Division of Technical Services
Cincinnati. Ohio 45226
July 1977
Far tajr by the Supenntri.drnt of Document*, U.S. Government
pilntinf Qfftc-e. W«ih>nglpn, D.C.
I I'u)
JO4O3
disclaimer
/
The contents of this report are reproduced herein as
ren*ived from the contractor.
The opinu.ns. findings. ..nd < inclusions expresscl herein are not necessarily those of the N.1lu.n d
Institute for Occupational Safety and Health, nor does mention of company names or products
products ..onstilute endorsement by the National Institute for Occupational Safely and Hea
NIOSH Project Officer: Loren L. Hatch
Contract # 210-76-01 IB
I
DHEW (NIOSH) Publication No. 77-179
I!
FOREWORD
An important objective of the National Institute for Occupational Safety and Health is the coordina
tion of delivery of occupational health care with general health care in the United States. Medical surv»..ilance requirements in standards promulgated by th. Department of Labor, based upon criteria
recommended by the National Institute for Occupaiional Safety and Health, will continue to increase
the demand for occupational physicians and nurses and other health professionals.
At present many businesses in order to provide needed services for their employees must rely upon
physicians and nurses who have no experience or special training in occupational health. NIOSH co
sponsored this 36th Congress with the American Medical Association in an effort to interest more
physicians and other health professionals in the recognition of occupational health problems in their
own practice.
The symposium speakers were selected because of their preeminence in the fields of occupational
medicine, nursing, industrial hygiene, and safety with the hope of encouraging a continuing educa
tional effort in this field, as well as to provide a review, for those interested, of the current status in oc
cupational health.
john Finklea. M.D.
Director. National Institute for
Occupational Safety and Health
Hi
PREFACE
The papers herein presented were first prepared for delivery at the 3Hth AMA Congress on Occupa
tional Safelv and Health. They were edited for publication by the contractor
These Svmposia an* intended Io furnish, over several visits, an introductory text highlighting the
.r petis of occupational medicine most significant Io part-time plant physicians. Io private medic.d
practitioners generallv. and to others w«'.h related interests. The concept arose from a 1974 NIOSH
survev of AMA-mernber physicians to determine the special problems and information needs of
thesi> physicians. Publication by NIOSH extends the availability of this text to the thousands of such
pliysn ians unable to attend the AMA Congresses, although a copy
>py of the appropriate volume is also
sent to each registrant at that Congress.
’! h«‘se manuscripts do not necessarily repri’sent the views of the National Institute for Occupational
Safely and Health, but do reflect the concerns that NIOSH has for occupational safc’y and health
They are being published for the benefit of those-unable to attend the conference and as a fului
reference for those interested in occupational health. Additional copies of the proceedings are availabk from the Division 01 Technical Services. NIOSH. Cincinnati. Ohio Suggestions and comments for
future Symposia .ire invited.
IV
'■’Mtrj-
ABSTR/XCT
This third volume of the Symposia is a continuing product of cooperation between NIOSII and the
r\merican Medical Association aimed at developing information to assist private practitioners with
pari turn* (Kcupalion.d medicine responsibilili(?s. The volume consists of papers presenletl
the
XIOSH m-sponsored 38th AMA (’ongress on Occupational Health conducted at Rochester. X Y m
September
and is published by NIOSI I. The Symposium topics were medical roles in woj kers
compensation: wh.it every physician should know about radiation: medical record keeping and sur
veillance: interdisciplinary teamwork in the health/safety professions: medical relationships with
unions and management: when workers fly: how to do a walk-through survev: and women at work.
The I97(» Congress was supported by a NIOSH-CDC Cost-Sharing Contract it 218.
IN MEMORIAM
Shortly after completing his work on these proceedings. Henry F. Howe. M il. passed away March (>.
1977.
He will he long remembered by those in the field of occupational medicine.
ACKNOWLEDGMENT
The NIOSH Project Officer wishe: to convey appreciation to Henry F. Howe. M D.. and Barbara S.
Jansson of the American Medical Association. Department of Environmental. Public and Occupa
tional Health: Marilyn K. Hutchinson. M.D.. of NIOSH: the individual authors who presented papers:
and all who took part by their attendance and lively discussions.
Also apprccialed are those NIOSH personnel listed below who took their time to provide critical
review and offer helpful suggestions for improving the content.
Lonce Ede. J.D.. DTS
Dawn Gillis. M.S.H.. M.S. (Chem ). DSHEFS
Austin Henschel. Ph D.. Consultant. DTS
Bernadine Kuchinski. R.N. (COHN). M.S.. DTMD
Charles Wisseman. M.D.. DSHEFS
vii
CONTENTS
MEDICAL ROLES IN WORKERS' COMPENSATION
Information Gathering
Marvin L. Amdur. M.D
Professional Services
Harold IL Imbus M l).. Sc. I)
Legal Aspects
John H. Lewis, j.l)
Workers’ Compensation Administration
f. Howard Bunn, fr
2
('
14
18
WHAT EVERY PHYSICIAN SHOULD KNOW ABOUT RADIATION
Problems of Ionizing Radiation
/. Newell Stannard. M.S.. Ph.D
Radiation and Occupational Health
.Sol M. Michaelson. D.V.M
Occupational Hazards from Non-ionizing Radiation
Thomas S. Ely. M.D............................................ ............................................
MEDICAL RECORDKEEPING AND SURVEILLANCE
Introduction
22
?2
-'1
48
Marcus M. Kry. M l)
Medical Record keeping
S O. Steiner. M.D
Health Surveillance in Industry
Ernest M. Dixon. M.D.. Sc. D
oO
59
INTERDISCIPLINARY TEAMWORK IN THE HEALTH/SAFETY PROFESSION
The Role of the Medical Profession
65
William D. Hoskin. M.l)
The Safety Engineer's Viewpoint
[>!vid V. MacCollum. P.E..
..............................................................................................
The Role ol the Nurse
Borhnni H(?uly.
..................................................................................................................
The Industrial Hygienist's Viewpoint
........................................................
Fronklin A.
MEDICAL RELATIONSHIPS WITH UNION AND MANAGEMENT
An Occupational Physician's Viewpoint
Alexander L. Strasser. M.D
WHEN WORKERS FLY
Problems of Flight Physiology
C. Craig Wright. M.D
Commercial Air Lines
75
73
86
98
107
Ludwift G. Lederer. M D.. Ph D.
Preceding page blank
71
ix
1
Preparing Workers for International Travel
Nicholas A. Pact?. M l)
General and Business Aviation
Bolx?rt I.. Wick. Jr., M.D
111
120
HOW TO DO A WALK-THROUGH SURVEY
The Industrial Hygienist’s Viewpoint
Marshall E. lxiNi<?r
The Physicrn’s Viewpoint
128
Donald I. Billmaicr. M l)
131
Thf‘ Role of the Occupational Health Nurse
Helen P. Onyolt. B.N.. B.S
137
WOMEN AT WORK
Pregnancy
Vilma R Hunt. A M
142
Making the Workplace Safe for Whom?
Kathleen M. Lucas. 1.1)
151
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MEDICAL ROLES IN
WORKERS’ COMPENSATION
Workers’ compensation has been altered by
time, social, political, and economic pres
sures. Most recently there has been a major
effort to get the states to upgrade their
workers' compensation systems. Recom
mendations of the 1972 National Commis
sion on St.ite Workmens Compensation
Laws have set minimal guidelines to bring
all states into compliance with a number of
recommended standards. 1 ht* inf(*ren(.e. of
course, is that if the states do not put their
respective houses in order to correct the ex
istent defects, the Federal Government will
do it for them. Some states are quite close to
full compliance: others have a greater dis
INFORMATION
GATHERING
tance Io travel. The major problems would
seem to lie in the extent of coverage and in
the levels of benefits paid. The love of
money may seem to be the root of all evil as
suggested by attempts to erode workers
compensation as an exclusive remedy
device by those who yet insist that it main
tain intact its no-fault principles. There is no
question but that major defects do exist and
Marvin L. Aindur. M.D.
these particularly in the .ireas of occupa
tional disease.
However much the external appearance of
workers’ compensation changes, it never
really changes its underclothes. It is
basically an adversary procedure into which
the physician may be thrust as a primary
performer. Unfortunately, in the entire pro
cess he may become a tool rather than an in
strument of justice and equity. Some artsis
of concern where I perceive the physician to
have vital roles in this somewhat imperfect
system include:
1.
’Vhe determination of causality.
2.
The determination of the nature
3.
and extent of disability.
The determination of the need for
treatment, the appropriateness of
treatment, and the application of
the principles ot rehabilitation to
workers’ compensation.
HORMR5 ' OWItSS Vl<»\
/
Physicians by training and by some subtle
selective process are methodical, orderly in
their thinking, professionally curious and
not easily pul down. Unfortunately,
although we may place ourselves just
slightly below the angels, we must admit to
some rather common human defects. Hav
ing made a diagnosis, physicians frequently
are loathe to retre.it from that position. Some
an* priggish and therefore vulnerable to the
blandishments and the manipulation of
those who would control and direct our
op.nions. Medicine is an art. not an exact
science, and for physicians to disagree is
peifectly natural Carrier and <*mployer
representatives, claimant representatives,
and administrators all play their part in this
sami game, revolving like satellites around
the central figure, the claimant, who may not
exactly be a member of an endangered
species. Whether the claimant alleges an in
dustrial accident or an occupational disease
depends upon thi* ease with which an ad
ministrative decision may be made under
either. No real problem obtains in the in
stance of an industrial accident. If it is estab
lished that the incident occurred out of and
in the course of covered employment, that is.
during the period of some 8 hours of the 24
as opposed to the 16 hours of uncovered,
non employment exposure, then causal rclationship for an industrial accident exists.
Once a decision as to causality, as well as a
decision as to disability, is made it can easily
be determined whether a schedule or nonschedule award would be in order. In the in
stance of occupational disease, however,
decisions of causality and the making of a
non-schedule award is often something less
than simple. Il is not surprising, then, that
under such circumstances the physician
may be frustrated, confused as to issues, and
therefore seemingly arbitrary in his opinion.
As a result, he may perform in less than a
sa’mfactory fashion.
There has been some activity of late seeking
to faulitale the efforts of the physician by
the establishment of guidelines. These, if
followed, result in consistently more equita
ble determinations of causality, al least in
matters of occupational disease. Two major
souri.es of such potential help are the United
:♦
States Department of Labor. Interdepart
mental Task Force on Workers’ Compensa
tion and the National Institute for Occupa
tional Safety and Health.
The complaint that too few instances of oc
cupational disease get into the system e.’her
by failure to report, by not being recognized,
or by purposeful concealment may well be
true. Acute exposures do occur in occupa
tional disease. The problems lie in the
characteristics of chronic disease, especially
the latency in onset and the lack of dis
tinguishing features as reflected in the
nature of the impairment. This impairment
may be indistinguishable from the effects of
normal aging or intercurrent disease. It may
reflect social abuse of drugs, alcohol, or
smoking; the adverse effects of medical
treatment: or the contribution of hereditary
predisposition. The disease may ielate to
organ system impairment and yet lack any
specificity as to agent. Adding to the confu
sion is the multiplicity of exposure and the
r ability of the work force which is the rule
rather than the exception in this country.
Finally, there is a possibility that occupa
tional disease may be visited upon the inno
cent who may have no direct exposure in the
work place. 1 refer, of course, to such things
as beryllium and asbestos neighborhood
disease, and disabilities affecting the un
born as a consequence of teratogenic and
mutagenic effects of exposure agents. These
all serve Io make more difficult the role of
the physician who must develop an opinion
with regard to the work-related; ess of the
disease. It is here that the physician exer
cises his orderliness of thought and must ap
proach his decision of work-relatedness
with reasonable medical certainty.
As in the diagnosis of disease due to an in
fectious agent where Koch’s postulates must
be fulfilled, so in an occupational disease,
the physician must be satisfied that the ex
hibited effects of the disease are compatible
with the known effects of the suspected
agent. There must be adequate evidence ol
hazard exposure, and epidemiological con
siderations should tend to support rather
than to deny any connection between the
demonstrated disease, its impairment, and
HOKKKKS COMPENSATION
the alleged agent. Unfortunately, these cri
teria may be fulfilled in a somewhat
nebulous fashion, and it is therefore necess
ary lor the physician to practice medicine as
an art rather than as an exact science'. The
physician must be alert, perceptive in his ap
proach to diagnosis and the assumption of
causality. H<' does not have to accept only
the obvious. Perhaps for loo long a time, we
have insisted on a body count before we
recognize causality. Perhaps we should have
been looking into the more subtle and less
obvious aspects ol :;i health such as per
sonality aberration, disturbances of sleep,
psychiatric complaint, suicide, juvenile
behavior defects, and learning difficulties.
A suspicion that nearly 85% of malignant
disease may in fact be environmental in
origin may well be true. If we accept this
premise, we should also suspect that much
of other illness may also be environmentally
induced though not necessarily workrelated. Il may be related to diet, atmos
pheric pollution, use of agricultural chemi
cals. food additives, drugs, and the effects of
a whole host of leisure activities.
Compliance with standards and codes does
not insure the absence of disease in indus
try. Threshold Limit Values (TLV's) are rubbery standards, certainly inexact in their
iletermination and inexact in their applica
tion. As physicians, our concerns must be
not necessarily with the health of ihe envinmmenl but certainly with the? health of
the workperson who is of such a
heterogeneous character as to defy any
uniformity of exposure tolerance. This is the
basis for Ihe action level principle, which 1
sincerely endorse, and which you will find
embodied in the Federal Regulations under
the Oci upational Safety and Health Act
(OSH.A). This sets a level of 50°:. of the ex
posure TLV. at w hich level there will be trig
gered the need for medical surveillance
along with engineering and administrative
controls by the employer.
If the physician finds it difficult to resolve
the problem of caus.d relationship in prim
ary ot;< upahonal disease, then he is going to
have infinitely more trouble in making sue!;
decisions of work-relatedness of disease
when occupational exposure has been com
plicated by the effects of any of the three
"A's." for example:
1.
2.
3.
Activation, as one sees when
tuberculosis becomes active in the
presence of exposure to silica and
siliceous materials.
Acceleration of dis<*ase. as in the
relationship between smoking and
bronchogenic carcinoma in
asbestos workers.
Aggravation, as w h en on e
superimposes right heart stress as
a consequence of pulmonary
fibrosis upon an already (‘Aisting
left heart strain due to increased
peripheral resistance for any
reason.
Hopefully, the physician will not make his
diagnosis of occupational disease by default
but will diligently inquire and obtain a
medical history to include travel, residence
since birth, social habits, medication, and all
leisure activities in which the claimant may
engage. His occupational history loo sl.uu’d
include his military service, and should con
cern itself with each and every empb »er in
a sequential fashion insofar as Ihe ci.am :nl
can recall. Il should include the duration of
employment, the nature of the work
assigned, the materials employeil. me physi
cal aspects of Ihe workplace. Ihe use of per
sonal protective equipment, and the ac
tivities of ancillary workers. Physical ex
amination should be as complete as he can
make it. and although it may increase the
volume of the report, the inclusion of
specific negative findings may be as valua
ble in the determination of causality as the
reporting of the positive ones.
A discerning and disciplined approach to
laboratory study is essential. It is improper
and wasteful to order reams of laboratory
work most of which may have but very little
direct relationship to the problem in hand.
Tht? physician who Would assess environ
mental sampling need not be qualified in ih»*
area of industrial hygiene, but he should be
satisfied 'hat the sampling is adequate, prop
HORMRS ( OMI'JASA H<>\
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f
erly collected, and the analysis competently
performed. He should be satisfied that it is
reported in terms expressing a level of ex
posure relevant to the problem surveyed. In
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cidentally. most employers will welcome a
personal inspection from a concerned
physician seeking information.
would then exist that whatever complaints
he had were work-related. Ibis, ol course,
bypasses the physician entirely. .A diagnosis
by presumption is worse than a diagnosis by
default. It would hardly seem that this coun
try could support a program where awards
for occupational disease may be made on
presumptions that fly in lhe face of fact.
Moreover, one could not Jeny anv worker in
The physician will not be so fortunate in his
any mill, factory, shop, or office the same
or
consideration offered the coal miner. Last
year. Social Security Administration dis
attempt
extract
to
from
a
vendor
manufacturer information as to the com
position of some of the products used in the
pensed
1
billion
dollars
for
black-lung
workplace. Hopefully, this will soon change.
benefits and this for a total work population
I’he physician must always remember that it
of 120.000 coal miners. In the same period, a
total disbursement for all other industrial ac
cidents and disease for lhe entire coveied
is his role only to inform the administrator
and not to adjudicate the* claim. The doctor
must not assume the role of an advocate for
population of these United States was 2 4
billion dollars. To ignore the physician and
either the claimant or th. employer. It is a
to exclude him from lhe decision-making
fact that often a funny thing happens to a
piece of good legislation on its way to an ad
process by substituting presumptions for his
input may well bankrupt the nation.
ministrative decision. The decision may per
vert the intent of legislation, but this is not
the doctor s area of concern. The parties to
dispute will exercise their prerogatives
under the law and the doctor s function will
be limited to his contribution Io the record of
the proceedings.
With the state of the art as it is today. 1 can
think of only one for certain and possibly a
second
medical
problem
which
may
by
presumption be attributable to occupation.
The first of these would be a mesothelioma,
suggesting asbestos exposure: the second is
’l he history of ‘Black Lung" legislation is an
illustration of what happens to physicians’
functions in the deli'rmin.ilion of causality
when social and political pressures become
paramount. I mention this simply as an il
lustration of what may well happen if
workers' compensation in general goes ti c
'Black Lung
legislation
angiosarcoma of the liver presumably as a
consetjuence of vinyl chloride exposure
The first 1 would accept without question.
The second m.ty well be rebuttable.
The second area in which I believe the
physician has a distinct role is in the deter
If
mination of the nature and extent of dis
workers' compensation under federal con
ability. I should point out that dts.ibilily per
s<* is not a medical determinant. It is <in ad
same route as
trol becomes part ot a National Health Plan
or is integrated
in
the Social Security
ministrative one
fhe physician must speak
System, then lhe decision-making process
may no longer be dependent upon
guidelines and reasonable medical
only in terms of impairment of function and
to some extent this is a reflection of
diligence.
for determining the level of compensation
which is to be paid to the claimant. It is the
The Federal dual Miners Health and Safely
Act of KK>9 provided black-lung benefits
physician who will define the impairment as
total or partial and. if the latter, then to wh.it
causality. The extent of disability is the basis
physical,
degiee. 11 is customary Io speak in such
physiological, or x-ray abnormality. Con
gress in its infinite wisdom in 1972 amended
the Act to insure that no mine • with al least
15 years of service in the mines would be
terms as mild, moderate, or marked to de
upon
the
demonstration
denied any
benefits. The
of
presump’ion
note the arbitrary gradations of 25% . 5(),,;>
and 75% . Where lhe claimant has some but
relatively little productive capacity, one may
refer Io the level as a high partial and for all
UOKRf KS • OMWASA 11< »\
practical purpose's a total disability. The*
physician must also be prepared to classify
such disability as being temporary or per
manent. \\ herexer the matlt'r of disability is
not clear-cut. it behoovtfs the physician to in
quire not into wh.it and how much dis
ability. but rather into the ■Why" of the1 disabililv. Wh.it are’ the* claimant’s oppor
tunities for se’condarv gain? Do the' high
levels of payment and the sec'mingly inexhauslabh' millin' of benefits s.ip the' clairnant s motivation to return to worl.? Doi's the
disability ndlect some' interpersonal incom
patibility m the' workplace'? Is disability a
reflection of domestic turmoil? Doe’s it
reflect an effort on the part of the claimant to
slough off moral and personal commitments
which, in the absence' of disability, socie'ly
would demand that the* claimant accept and
respond Io?
Let me briefly make comment on several
devices I employ Io assess medical impair
ment These include observation of gait, and
the ability to undress and dress again with
ease. I have one examination area which can
be reached by ascending a single flight of
stair ;. This serves as an excellent device to
test tolerance to exertion. I frequently ask to
see the claimant s operator’s license to note
such restriclions as may be described
thereon and also to look for citations as a
reflection of the claimant's behavior and
personality I regard as suspicious any
claimuni who drive.*- to his examination and
does not have <i license? with him.
Perhaps one of my most productive ejuestiuns is "How is your sex lift!?" This usually
take s the claimant by surprise*. The level of
interest and performance varies inversely
with the level of disability. I do make in
quiry as to the claimant's economic status. Is
he living at home, does he own his own
home? Is he married: is his wile working?
How many c.hildren do they have? What is
his aggregate monthly payment and from
where is it coming? Armed with such infor
mation. I think the physician is in a fair way
Io ma!<“ a determination with his head and
not with his heart.
The third and final area where* I regard the
HOKMKS • OMFESS \7 I<>\
physician .is having a vital role? relati's to
treatment and rehabilitation. The? relation
ship be*tween the patient and the' physician
is a sacrosanct one', and no age'ney or in
dividual in his right mind would presume? to
invade* or to alter it—that i<. just so long .is
the* patient is reisponsibh' for his own can?.
Toelay. howe*ver. in an e*ra of third party
paye'is. be* they employer, carrier, or agt'iicy
of the fe‘de?ral. slate*, or local government.
the*re? is a sueldem realization that poe:ke‘ts are'
not as di'e'p as they we're' suppose’d Io be. anil
that funds are’ not as unlimited as they
see'ine'd to be just a few months ago. The're*
are* all sorts of elevici's monitoring not only
elelive'ry of health care1 but its quality and its
e:ost e'ffeclive*ness. Workers' compensation
is no exception. (Carriers and employers
have the' right Io question, but the’y cannot
eh'ny authorization or altiT medical c.are*
without medie:al opinion. /Xelminislrators,
too. in the instance'of apparent impasse will
se'i'k to resolve? it with impartial medical ex
aminations. anil I suppose in some jurisdic
tion there may be panels of examiners for
the same purpose. In those* instances of
protracted treatment where the effec.ts may
be brief and of no enduring value, the
n*commenilation Io terminate such treat
ment may be made and the issue:, presented
for administrative decision.
'I’lu? companion process Io workers' com
pensation is rehabilitation. It is this proci*ss
which may keep workers' compensation
programs from simply becoming dispensers
of funds as awards for existent defects, or.
as they sometimes seem Io be. rewards for
having been inju/ed. Any program of
workers’ compensatir n which does not in
clude a program looki'.g Io restoration, if al
all possible. Io form r economic and social
status is bereft of purpose and dignilv. Only
through the efforts of physicians dedicated
to the goals of rehabilitation, can these aims
be achieved. Physicians must assess in.pair
men! and plan for rehabilitation. They nusl
begin Io do this early in the course of any
dis<d)ility. Physicians recpiire the expertise
of those of us who understand the .lemands
of Iht* work environment, and our input is
(essential. Then* can be no rehabilitation
without medical guidance I he physic.lan
must be knowledgeable in areas of com
munity resources including the functioning
of the various government agencies, state
education departments. Offices of Voca
tional Rehabilitation. Social Security Admin
istrations. social welfare agencies, and those
agencies whose names and functions are
mon* popularly known, including Easter
Seals and the blind and lung associations.
zXI! of this takes on special urgency as a con
sequence of the Federal Rehabilitation Act
of 1973 with its affirmative action provisions
and with its punitive provisions, pariicuiurly
for those industries with federal contracts.
I have attempted to show how a workers’
compensation system cannot function with
out physicians and how physicians might be
well advised not to ignore their respon
sibilities. To do so will be to invite changes
which will reduct! and almost deny to the
physician any function beyond that of trea*men I. and then probably in a most
restrained and limited fashion.
HORKfRS < •CIMFIASAThn
PROFESSIONAL SERVICES
Harold B. Imbus. MJ).. Sc.I).
Since lhe workers' cumjiensalion system is
one designed to provide medic.d care and
compensation for the worker who is injured
or ill from his work, lhe physician has al
ways had an important role. Traditionally,
physicians have been involved with th«‘
diagnosis, treatment, rehabilitation. and
.issessmenl of disability for workers under
lhe workers' compensation system. Some
physicians have for many years been in
volved in preventive programs to keep lhe
worker from needing compensation or
medical care in the first place. This rob? is
increasing rapidly in recent years. Finally,
when it comes Io policy decisions, both in
side and outside lhe corporal:
and in I’m*
broader realm of public dec ^.ion-making,
physicians have had a varying roll? depend
ing upon lheir influence and the locality, hut
in lhe years that I have Deen involved in oc
cupational medicine their role seems Io have
been largely passive. I would like Io discuss
lhe physician s role in the worki'rs* compen
sation system under lhe headings of: Pre
vention. Diagnosis. Treatment. Rehabilita
tion, andlnpul Into Policy Decisions.
PREVENTION
In my opinion, prevention should be lhe pri
mary role of lhe physician. This is not a rob*
thi’ physician can assume alone. It is an
effort involving multiple disciplines includ
ing management. th<* safety engineer, lhe in
dustrial hygienist, the nurse, lhe ergonomist,
lhe industrial engineer, and the worker. The
physician is in a position to assess the interaciion between the work environment
and the worker. There is an increasing body
of literature about these interactions, and
certainly the physician on the work site
should make his own observations. An out
standing example of this is the recent dis
covery of angiosarcoma of lhe liver due Io
vinyl chloride exposure by the astute physi
cian. John !,. Creech. M.D. at the B.F.
Goodrich plant in Louisville. Kentucky. It is
quite likely that other astute physicians will
discover similar associations in lhe future.
ItOKMXS COMI'f xs\I’<>\
K
Broad policy concerning prevention is now
being determined by OSH A standards. I he
physician should have an input into the
dev» lopmenl of these and also in their local
application in the plant. However, it is very
likely that regardless of the excellence of
preventive efforts, workers compensation
cases, especially for occupational disease,
will continue to increase. There are several
factors in ‘his:
i.
The discovery of new occupational
diseases and associations between
work environment and disease
heretofore unknown.
t\ general trend of more broadly
interpreted definitions of occupa
tional injury and disease to include
conditions previously not included
in the system.
occupational diseases. Long latency periods
and the fad that occupational diseases can
be indistinguishable from ordinary diseases
make the problem of diagnosis extremely
difficult in many cases. Nevertheless, in
spite of these difficulties, the.re are rational
approaches to the diagnosis of the individual
patient, and then* are epidemiologic,
measures which can be used to assess the
incidence of occupational diseases in groups
of employees.
Many fine articles and books have been
written concerning diagnosis and treatment
of these conditions Until recently, for the
most part, diagnosis was confined to diag
nosing the extent of trauma. 1 his is fairly
clear-cut in most instances. However, prob
lems. when they did arise, usually were in
the form of a delaved and non-obvious
manifestation of a trauma: for example, a
patient with a leg injury two weeks later
With respect to individual diagnosis, there
are several important aspects which .ire
fairly obvious. Many of us. however, over
look one or the other at times, and therefore
may make an erroneous diagnosis. The diag
nosing physician needs Io know the
manifestations of occupational diseases.
These manifestations may be specific or
nonspecific. Eor example, silicosis and coaf
miners pneumoconiosis have pathologic
findings that are reasonably specific for
these diseases. These findings would enable
.1 diagnosis by a pathologist from a biopsy or
autopsy specimen. However, most occupa
tional diseases have a set of manifestations
that are not specific, but are characteristic of
the exposure. Thi' organs of the body have a
limited \ ariety of responses Io various exter
nal insults and may respond in a single way
Io a large number of agents. /\ thorough
history and physical examination should be
included in the diagnosis of occupational
diseases. Laboratory tests would include
those for the general assessment of health,
nonspecific tests of exposures such as
serum glutamic oxaloacetic transaminase
(SCOT), lactic dehydrogenase | I.DH 1. EEV j.
tests for the agent or its metabolite that indi
cate exposure, and tests th.it establish a high
susceptibility to a disiMse or condition. An
evaluation of exposure must be made both
from occupational history and indtis’rial hy
giene data where it exists Once the physi
cian has m.ide these evaluations, he must
then exercise clinical judgment in making a
diagnosis In my opinion, making these
diagnoses of relationship of the patient s
develops low buck pain, and the <pi<-stion is
condition to the workphe <• exposure in a
whether there is a relationship Though
these problems are difficult, they in no way
appro.u.h the magnitude and difficulty ncreasmgly encountered in the diagnosis of
careful and unbiased manner is one of the
most significant roles that the physician has
in the workers' compensation system as i*
presently exists.
Therefore, those involved with the prevenlive effort will find it increasingly difficult to
measure their success if they base it purely
upon the number of workers' compensation
cases. Though this may be discouraging to
some and may be difficult to explain to some
managements, real success in this effort
should lie based upon the number of in
dividuals removed from exposure, the
decreased incidence of clear-cut injuries
and occupational diseases, the stabilization
of chronic disease processes affected by ex
posure .such .is hearing loss, lung disease,
and so forth
DIAGNOSIS AND TREATMENT
HOKKf RS I OMITSS \ I IOS.
'I
TREATMENT AND REHABILITATION
Here the ultimate goal is to treat and to cure
the worker, and where more is not possible,
to rehabilitate—to enable the worker to con
tinue working with some accommodation to
his problem. Treatment of course involves
the specific treatment for the condition.
zXdded to this. howt'ViT. is a consideration of
the need to prevent or modify continued ex
posure. and the need to evaluate physical
capability to do the job in tpiestion. In addi
tion. the physician needs to understand
some of the other interactions which art*
often peculiar to occupational problems-the feelings of the employee, good or bad.
toward the employer, and v ice versa: and the
interactions and influence of those repre
senting the employee, on the one hand, and
those representing the employer, on the
other hand. At times, he may be able to be an
influence in modifying some of the adver
sarial relationships that develop. Though it
is the role of those representing employee or
employer to see that the r(‘spective security
and financial interests are protected, the
physician’s primary role must be to sec that
the patient recovers and returns to pro
ductive activity, if .it all possible. Sometimes
the adversarial na.ure of the workers com
pensation system iclually impedes this pro
cess: and the physician, when he sees this
developing, should use whatever influence
he can to p~evert these problems from
delaying the ullini<ite rehabilitation.
Rehabilitation is an important medical role
in the workers' compensation system. The
injured worker loses physically, mentally,
and financially while he is unable to work.
Early return to work compatible with his
capability often before full recovery has
taken place, is beneficial, provided this is
done with good medical judgment end care.
For practical purposes, rehabilitation can be
considered in two phases: t 1) off-the-job
rehabilitation and (21 on-the-job rehabilita
tion. The former includes those efforts ot the
attending phvsician and rehabilitation
specialists such as physical therapy, voca
tional training care and rehabilitation cen
ters. sheltered workshops, specialized work
capacity determinations (such as cardiac
work-evaluation (enters) to determine fitUORkr-KVf (T.1P* ss\7HI\
nrss to work in special situations. The
physician should see that these resources
arc fully utilized.
In addition, an often neglected aspect to
rehabilitation is the on-ihe-job rehabilita
tion. It is a team approach utilizing the (.am
bined services of attending phvsician. oc
cupational physician and/or occupational
health nurse, and employer. It is an exten
sion of off-the-job reh.ihilitation often ovt ilapping with it. Necessarv to on-th?-jab
rehabilitation an* the following:
I.
2.
3.
4
5.
7.
lnl<T(‘sl of the employer and the
occupational health team dining
the illness.
Physical and psychologit al medi
cal evaluation from an occupa
tional viewpoint prior to return to
work.
Job evaluation from a viewpoint of
physical and emotion.d demands
Employers understanding ot the
employee's problem.
Motivation and reassurance of the
employee.
Modified work and/oi gradual
resumption of full duties.
Follow-up bv the occupaiiona!
health team
The physician should evaluate whether c*r
not these elements are nn'sent at the w.'rk
site, and his role would be one of attempting
to see that satisfactory on-the-job rehabilita
tion programs are in effect. This wdl effort
earlv return Io work in many cases.
INPUT INTO POLICY DECISIONS
Methods and amount of compensation .ire
basically politic.il dt*( isions decided upon hv
federal and stale governments Though the
phvsician may participate in this politu ii
process, as any citizen, depending upon his
convictions and affiliations, it seems that th*
real role of the physician is to see dial ado
(piale scientific in formation is delivered to
the decision makers
manv instances
workers' compensation legislation has at
tempted to use »he best available scienlitir
eviilen'ce. This is becoming increasingly
ip
difficult due to the recognition of long latent
periods in the development of such diseases
as occupational cancer and occupational
lung id. “use. We are increasingly recogni
zing the ii. '’•'action of various chemic.als
and environmei. ’* agents with the persons
genetic disposition, physical condition, and
other off-the-job environmental exposures,
such as noise, smoking and air pollution.
As an example of one of our current prob
lems. let us discuss occupational lung dis
ease. Most present-day lung disease is en
vironmental in origin, that is. due to some
type of inhaled substance or microorganism.
In fact, most of our serious lung diseases to
day are not due to microorganisms, but to
non -living organic or mineral substances in
haled into the lungs.
Earlier ( lassie forms of occupational lung
disease often had fairly discrete clinical,
laboratory, or pathological findings. Now.
many of the occupational lung diseases
which <ire being described, both neoplastic
and non-neoplastic, cannot readily be
differentlaled by the aforementioned means
from non-occupational lung diseases due to
inhaled pollutants such as cigarette smoke
or environ mental air pollution. I his is not
surprising in view of the following:
1 l-'.arlier described occupational lung dis
eases were discovered wi’h fat less sophisti
cated measures than now available and
therefore would be expected Io be more ob
vious.
2. Modern clinical, laboratory, and
epidemiological methods of assessing
groups and relating the health of these
groups to more sophisticated environmental
measurements would be expected to result
in improved finding of lung diseases associ
ated with the environment.
3. It is general’.'-’ accepted that the lung, like
other tissue, has or-.lv a limited number of
ways in which it can respond Io environ
mental insults Thus, the response may be
fibrosis, granuloma, bronchitis,
emphysema, and so forth, and though in
some cases these may be somewhat specific
to the agent described, such as in the case of
asbestosis or silicosis, ibis may not
necessarib be so. as in the case of chemical
bronchitis, chemical allergy, or chronic
obstructive lung disease due Io cotton dust.
Though this development of detection of
heretofore undescrib(‘d occupational dis
eases creates significant opportunities for
prevention, it also creates a dilemma for the
clinician who is attempting Io diagnose the
(.ondition.
So.nr of the choices that have been advo
cated to deal with this problem are presump
tions. criteria of diagnosis, and specific diag
nostic tests.
Presumptions have been advocated both as
to the existence and non-existence of oc
cupational disease. In the past, the presump
tion often was that a condition was non-oc
cupational unless it could be proven to be
occupational. More recently, presumptions
are being advocated in the opposite direc
tion. If a condition occurs that may be com
patible with the exposure, ii will be
presumed that the condition is due Io the ex
posure regardless of other interrelated fac
tors.
.
In the workers’ compensation area, the
negative presumption may rt’sull in a num
ber of workers not receiving workers com
pensation for an occupational disease which
they indeed do have, while positive
presumptions will result in many employees
receiving compensation for non-occupational disease?. For example, a number of
surveys of presumably healthy groups ex
posed to no known occupational pollutant
have shown an incidence of significant
chronic, lung disease as high .is 20% .
Therefore, it is possible, under the positive
presumption, that if a group exposed to an
occupational pollutant has a 10% increased
incidence of disability, over and above the
non -exposed group, th.it 3(1% rather than
10% will receive workers’ compensation
Argiiincnts for and against a syslem of negaUORM.KS ( (JMItXSUKA
11
live or positive presumptions can he made,
and in reality the ultimate choice must he a
political decision based upon factors other
than medical consideratitms However, if
society and its politicians are asked to make
this choice, it should he on the basis of a
clear presentation of dilemmas and the costs
involved, to the worker, to industry, and/or
to taxpayers. Possible injustices either to
employers or industrial groups should be
measured carefully. Even some of those
who favor negative or positive presumptions
admit that this is a course of last resort and
one based upon the lack of exact scientific
knowledge for diagnosis. In view of the tre
mendous potential costs involved on the one
hand to employees who may not be compen
sated f..r an occupational condition, and on
the other hand, to industry or taxpayers who
may be compensating for non occupational
conditions such as smoking, it seems desira
ble to consider methods other than
presumptions. In addition, if the presump
tion method does become wid. pread for
large industrial groups, it is \
. okely that
this will greatly change the [ sent system
of workers' compensation versus general
sickness compensation for occupational ver
sus ncn-occupational disease.
VVe have dealt above with some of the prob
lems of using presumptions in the workers'
compensation system. Other problems of
presumptions are the? fact that using them
may result in some lack of motivation on the
part of individuals, industry, and govern
ment to clearly define the causative nature
of occupational lung disease and the interac
tion ’hereof. Environmental controls to
reduce pollutants are expensive, and if all
cases of lung disease are considmi’d due to
occupation whereas only a small percentage
really art' there may be a feeling that then* is
a situation which cannot be controlled no
matter what; and therefore, incentives to
truly control it may be diminished. Money
spent on compensation cannot be spent on
abatement.
Rf’gard’pss of whether a system of presump
tion is finally adopted, it appears in view of
the .iforememtioned difficulties that other
methods of delineating the etiology of lung
UOHM.K’* <
\ IU)\
disease in an exposed employee merit
serious consideration.
Criteria of Diagnosis Presently with many
occupational lung diseases there is enough
similarity Io non-occupational lung diseases
that there is no definite way Io make a diag
nosis. However, there are situations in
which epidemiological studies can assist in
the development of criteria diagnosis. These
are never as precise as specific diagnostic
tests such as biopsy or enzyme determina
tions. as in alpha-l-antitrypsin deficiimcy.
However, they often are of considerable
assistance in making a diagnosis which can
be used in guidance Io the individual. Io lhe
industry, and for medico-legal purposes. For
example, a criterion of diagnosis may be
based upon a history of exposure to signifi
cant amounts of the offending substance, ademonstration of physiologic changes, such
as pulmonary function, and/or radiological
changes compatible with lhe occupational
lung disease. Judgmental factors for other
exposures such as cigarette smoking may or
may not be inserted into the criteria.
Criteria for diagnosis have been used by
clinicians for many years in both occupa
tional and non-occupational conditions. An
example would be the {ones Criteria for the
diagnosis of rheumatic fever in which the
presence of two major manifestations or one
major and two minor manifestations indi
cate the high probability of the presence of
rheumatic fever, if supported by evidence of
a preceding streptococcal infection.
However, such criteria of diagnosis will al
ways be somewhat arbitrary and may lend
to exclude positive or negative diagnosis. In
spite of these deficiencies, they do offer cri
teria which in some cases can be generally
agreed upon and which can offer definite
guidelines for counseling with individuals,
management, and for medico-legal pur
poses. Therefore, it is believed that t-horough
review and research concerning diagnostic
tests and criteria for diagnosis of the various
occupational lung diseases should be a high
priority.
Specific Diagnostic Tests It is obvious that
a specific c iagnostic test for a particular oc12
cupational dibrase is the most desirable
means of making the diagnosis. Specific
test:, have be<‘n developed for a number of
medical conditions, usually non-occupational. Obvious examples would be cardiac
stress testing, coronary angiography, and
G.l. series for diagnosis of peptic ulcer.
Though t‘ven the so-called tests may not be
of absolute certainty, they neverlh<»less an*
considered in most cases highly reliable and
offer a reasonable degree of medical proof
that the condition does exist, in the area of
new occupational diseases, especially lung
diseases, there is a paucity of specific tests.
This, obviously, is to be expected since
many of the occupational lung diseases <ire
con fused with or represent a com bination of
etiologies. Nevertheless, due Io the impor
tance of this matter, resi’.irch should be
directed toward better diagnostic, techniques
utilizing specific le‘Sy» if they can be
developi’d. Obviously, research aimed at
developing specific diagnostic tests may in
many cases be premature, since the develop
ment of these tests would depend upon a
better understanding of the etiology and
I I
pathogenesis of the disease. Conversely,
work directed toward developing bi-lt'T
diagnostic methods can add to our under
standing of the etiology and pathogenesis ut
the condition. Some of the <ireas that deserve
further research and evaluation are: im
munology. physiologic tests, pathologic tests,
and chemical laboratory studies.
Occupatic-nai lung disease is just one of
many areas of concern. 1 have outlined some
of these problems and proposed solutions '
facing us today. The medical/scientific com
munity can make a very substantial con
tribution in dealing with these problems in
developing ade(piat( scientific evidence and
methodology. When such evidence and
iru'thodology do not exist, the medical com
munity can also make a substantial con
tribi'tion by clearly defining and articulating
the* probl. mr. that do exist, by clearly letting
the American public know when there is not
adequate scientific evidence, and by point
ing out the problems involved and the
various choices available in dealing with this
matter.
llORM-RV (OMI-I V \TK>\
I must adinit Io a bit of trepidation over
being here today, since it is impossible to
talk about this subject matter without ex
pressing at least a small amount of criticism
of the medical profession. 1 hope that you
might be persuaded Io listen with open
minds: I want you to know that I have never
filed a medical malpractice action!
LEGAL ASPECTS
The impact of medical services on worki rs'
compensalion is immense. Many states re
port that over 30% of the benefits delivered
during the year are payments for medical
services which means that we are talking
about hundreds of millions of dollars. The
direct monetary impact on lhe system,
however, may actually be over-shadowed bv
the importance of the medical profession's
indirect influence on lhe entire compensa
tion program.
DEGREE OF IMPAIRMENT
John H. Lewis, J.D.
Many doctors, \vhen questioned about their
role in compensation cases, profess to have
only an incidental and technical involve
ment. They maintain that their only concarm
is to treat theii patients, whether compensa
tion recipient or private; patient, anti to re
port on the condition of the patient as treat
ment progresses, to the point of complete
cure, or maximum medi".al improvement
with residual physical impairment. Il is then
supposed to be up to the insurance carriers,
attorneys, anti agency personnel to resolve
the troublesome issues that arise in compen
sation cases. The physician with that attitude
evidently doesn’t realize that his inilia! diag
nosis may be lhe determining factor in
deciding whether a claimant's condition is
compensable, and thus may control the en
tile benefit package.
The duration of temporary disability
benefits will be controlled almost entirely
by a physician s opinion, generally lh.it of
lhe treating physician, as to lhe need for
treatment and rest. If permanency exists.
WORXFRS- COMPFAS ATinS
i?
■
■
I
■
fe
and thr inptrv is *<> m hrdulrd mrmlx’r. iht*
benefits p..;d will be determined by a doc
tor's opinion .is to the decree of impairment.
Even when the award for permanency is
based upon fa< tors sui h .is loss of wage
earning rapacity, the final determination is
usuallv based upon medical opinion as to
what physical activities the claimant is abh*
to undertake This is certainlv more than an
incidental impact
COMPLEXITY OF CASE
I
i.
The question of lhe physician’s .itlitude is
also important as it < an be one of lhe major
obstacles that exist to improved relations
between physic ians and others in the com
pensation system .Although my specific
topic deals with the legal aspects of the
phvsnn.m s role in workers’ compensation,
due to the* nature of lhe c cimpensation
system it is not only difficult but self-defeat
ing to trv to separate legal aspects from other
asports of the* system Many, if not all partic
ipants. look upon the doctor .is anything but
a neutral f.ictor in the operation of the* com
pensation program II is seldom that an in
jured employee' or his attorney will view a
dcM tor selec ted bv the emplover or carrier as
anvti.'ng other th.in a ‘ c ciinpanv doctor." a
term w h. h has extremely negative connota
tions’ for m.mv compensation recipients.
Simdarh . employers and < .-.Triers look with
I'cpiai distrust at phy dcians retaint'd by
claimants and then attorneys, and view
them as part of lhe claimant s team.” Often
these' feelings are unjustified and without
basis in fact resulting only from institu
tional attitudes developed over the years.
However many physicians either inten
tionally or unintentionallv conduit them
selves in a m.inner which lends credence to
these beliefs.
because of the patient’s belief that no is not
being treated fairly by his physic'an. ()bvio.isly these feelings may some times be un
justified. but you must realize ib.it injuries
art* important events in the lives oi workt rs.
particularly when they cause loss of income
am! fears about one’s ability to return Io a
productive life.
The demands of a busy practice can be over
whelming. but so can the effects of failing to
provide the patient with a reasonable
amount of information and je.esuranctt
about his condition. Quite often doctors
make this problem even greater by simply
informing lhe patient that they cannot pro
vide him with any information whatsoever,
and stale that he has to confer with his
employer, its insurance, carrier, or an at
torney in order to find out how he is doing
and what his prospects ai«.. I can assure you
that this virtually guarantees that the in
dividual will wind up with an attorney and
in litigation, if for no other reason th in Io
obtain a change of treating physician.
OBJECTIVITY OF OPINION
Su< h conduct, usually un inleuhonal. is
generally brought aboul by lhe immense
pressures under whit h many plvsicians
must operate, e.g.. poor communi alit n with
.i patient This, p.iiiiculajl. v-F n lhe doctor
has been selected in some way by lhe
An equally important factor is the deter
mination by a number of doctors that they
are in fad not neutral and owe son'e tvpe of
obligation Io the particular side that they an*
‘ representing." Most compensaiim pro
grams make use of a procedure which per
mits lhe adjudicator or one of the parties to
select a physician to conduct in examina
tion. for the purpose of testify ing at the hear
ing. There are conservative doctors and
liberal doctors, in terms of their i valuation
of a patient's condition, but one must ques
tion whether statements made by doctors
that they feel an obligation to assist the side
that has requested their services either com
ports with the physician's code ;»f eP'iics or
provides any meaningful assistance to lhe
compensation system. The practical result is
to require a! least two physicians tn each
case, one "liberal" and lhe other "conserva
tive." with a resulting decision that is more
<‘flrn than not somewhere in I ‘’tween the
« an xirlu.dlv o- -.troy tl
doctor
two epin ions, tn met repel it .in areas this pro
patient relationship. All of us are familiar
weh many cases in which a routine injury
has bet tune a complicated < ase primarily
cedure has reached such levels ot sophistica
tion as to cause unnecessary exi’irndilure of
Mibslantial sums of monev.
f
w»)NMtrs
xiios
In the area of no-fault automobile insurance,
statutes in some stales require that a
' threshold" of lost wages and medical ex
pense be reached before a suit can be
brought against a negligent parly. After the
implementation of these statutes, injuries
which never required more th.in S200 to
S300 in medical serv c.es al. of a sudden required weeks of hospitalization, serial xrays. and other expenses which in many
cases miiaculously cami* Io SlOor S20 above
the threshold. Tins reipiires an unfortunate
kind of cooperation between members of
the medical and legal professions, and we
know lh.it the same cooperation exists in
compensation c.ises with regard to issues
such .is duration of temporary disability, ex
tent of permanent disability, and need for
active treatment. Obviously the legal profes
sion has to accept al least half the blame, but
by the same token. these activities cannot oc
cur without the active participation of some
members of ih<’ medical profession And it
is not only claimants’ representatives who
an* involved m these actions. Many in
surance carriers have continuing relation
ships with physicians, and they expect con
sideration of that relationship when the time
comes for the expression of medical opi
nions on issues of causation and extent and
duration of disability.
I want Io emphasize that I am not miking
about differences of opinion. There ar<‘
many subjective factors to be considered in
developing a medical opinion, and even the
use of the AM.A Guides to the Evaluation of
Permanent Impairment does not guarantee
identical opinions when two doctors deal
with the same ( ase. This is Io be expected.
What we are talking about is the delilierate
distortion of opinion by physicians who arc
supposed to be neutral participants in the
compens.ilion program.
EXTENT OF PROBLEM
The problem is getting worse, not belter. Ev
ery vear we see more and more cases com
ing into the compensatioii system, due Io in( reas«'s hi the r.'iviTed work fort.**. /\'so. it
appears that we .ire becoming more litigious
and what war. intended to be a system
opi rating with .< minimum of controversy is
IIOKMVS •
rapidly becoming a battleground. But there
remains on the horizon another factor which
may create an even greater strain on
w nr k?rs ’ co m p e n s a I i o n p r o g r a m s
throughout the country. 1 am referring Io the
problem of occupationally-related diseases.
We still do not know the magnitude of the
problem in terms of the incidence of cases.
What we do know is that occupational dis
ease cases create difficult medical issues
and presen' increased opportunities tor
abuse of the system.
When workers’ compensation agencies
fulfill their obligations and provide ad
judicators who can often determine when a
physician is playing an inappropriate role in
a compensation case, and rule accordingly,
the opportunities for abuse an minimized
and the incentives to play these games are
reduced. While a well trained and well moti
vated judge or referee can quite often
develop the necessary skills Io reach such
determinations in c.ises involving traumatic
injuries, it is virtually impossible Io do so in
instances of disease. The medical issues are
far too complex and technical to be readily
compn*hended by even a skilled layman:
and as a result, there must be almost com
plete reliance on medical expi’rts in order to
establish causation and the other legal issues
which must be resolved in every compensa
tion case.
There an* many unanswered questions in
the field of occupational disease, and a great
deal of disagreement. <'ven among the ex
perts. We don’t need to compound the
difficulties that Ibis slate of affairs creates by
having doctors testify on issues about which
they have little knowledge, or try Io treat
cases which are beyond their expertise. This
quite ofte.1 happens with the best of inten
tions. The motives may be of the highest
order, but the compensation system oper
ates and is funded on the basis of a number
of legal considerations, and altruism is not
one of them In addition, the compensation
system is not intended to fill the rides of a
national health program or a national in
come replacement program
The problems do no! all come from the
x ’-'os
jWid'nr'
cl iimanls' side. Then* has been a tendency
for some physicians retained by individual
firms or industry associations to take posi
tions on the industrial causation or even the
existence of disease conditions which
lacked even .1 minimal degree of openmindedness. 1 can recall in very recent years
asst*dions that byssinosis was not a disease,
but rather a figment of the imagination.
Equally absurd opinions have been heard in
the debatt* over pneumoconiosis, and I am
certain, that they will appear from time to
time whenever another major diseast* prob
lem is found.
In..terms of the (lifficultics of the compensa
tion svs!em. there is mon* than a grain of
truth in th»* statement made about malprac
tice: The medical profession could solve the
problem if it would only police Hs own
members. Obviously, the legal profession
must take steps to find and discipline those
attorneys who an* abusing their role in the*
compensi.tion svsterr.. To do this, medical
tesiimonv is often indispensable in proving
misconduct, tesiimonv that is often difficult
to e.btain even in the most blatant cases.
even when economically justified, is the
deeply ingrained feeling that .1 good portion
of such increases will go to doctors who are
abusing the workers' compensation pro
gram. Employe’s and insurant.t* c.irrit*rs are
often more than willing to pay customary
and usual fees for services rendered in com
pensation cases as long as the sen ices pro
vided to compensation recipients art* per
formed in the same m.inner and to the same
extent as those provided to private patients,
and that the doctors involved will retain the
role of physician, and not .idvoc.ile.
The same holds true for the bunlens placed
upon the physician by demands for form fil
ing and testimony. Certain forms must be
filed with compensation agencies and/or
carriers to advise them of the tn*atment
being provided and its costs. However, the
frequ mey of these reports and the detail re
quired. in part, reflect a lack of ’rust and an
unwillingness to permit the physician to
render medical care Io compensation pa
tients without close oversight to prevent
abuse. This mav appear unfair and unwar
ranted. but it is a s.id reality that must be
fac<*d.
The experimental peer review programs
which are now being used in some areas
need ’o be refined and expanded so th.it the
opportunities to defraud the compensation
system will be minimized and made less at
tractive Physician:; net d to lie educated as
to their proper role in the compensation progiam. so that they can go back to practicing
medicira- and leave the representation of
claimants tn the attorneys.
Why should the physician do anything for a
system that quite often burdens him with
paperwork, pavs inadequate fees, and
embroils him in controversies which take
him out ol his office and into the courtroom
Not from altruism, but out of enlightened
selt-interest. Based on experience in Florida
in considering the adequ.icy. or inadequacy,
o’ medical fee schedules, one id the major
objections to increasing the level of fees.
Similarly, the need for medical testimony
can be reduced if the physician provides
prompl. comprehensivi*. and lucid reports
as to the issues which may be involved in a
compensation < ase The demand for
testimony is quih* often based not upon the
need for information, but upon the often
reasonable belief that a doctor will advocate
a position, or expressions of opinion If Ibis
is done without substantial basis, it < an be
exposed through cross-examination
In conclusion, the objectives of a workers'
compensation program are best served and
the claimant is certainly best served, by a
system which oper.des with a minimum of
game playing and abuse. I he achievement
of such a system is not totally within the
physician s control, but without his help. :t is
unattainable.
UORk*
< oxti-r ss \ n<>\
WORKERS’
COMPENSATION
ADMINISTRATION
J. I Inward Bunn. )r.
The main thing which I think is important io
Che relationship of the physician in the
workers’ ;ompensalion system is the need
for physicians to know move about the
system, to understand what it is for. an*.! un
derstand how it operates. W<- attorneys often
criticize the medical profession for not un
derstanding the workers’ compimsation
system, its statutes and regulations- but the
legal pr<Session, my own profession, is just
as guilty. The law schools spend very hille
time on workers’ compensation laws, and .
expect th«il the case is the same with the
medical profession, that those of you who
went through medical school got practically
nothing about workers’ compensation. This
points out two things. Then? is a distinct
neeci for the medical schools in this counlry
Io spend some portion of time during the
curriculum to let students know genei'-diy
what workers’ compensation is about. There
is also a need after physicians leave medical
school for continuing education courses Io
teach them the provisions of workers’ com
pensation laws in their slate and how these
laws are administered.
In a session of this type, we can give you
only a broad overview of workers’ compi nsalion and some of the problems. Individual
stale workers’ compensation programs are
still strictly stale programs; and while then*
are main similar problems in the varime
workers’ compensation agencies ami lavvs.
there are also many differences in the laws,
so that to really grasp how your particular
agtmcy operates or how your particular laws
function you i.eed Io contact the workers’
cc.nnpensalion agency in your particular
slate.
Secondlv. the medical profession needs to
assess the problems of the profession wdh
workers' compens.ilion in a given state
There may be a problem in fee schmiules
There may Ise a need f<”- special procedmes
to diagnose* oci up.itional diseases. I’hen
may be problems m understanding what the
ttOKMK'* < OMPfASAirox
1H
workers' compensation agency wants in the
way of ratings. There may be problems in
understanding the forms they require. In
these matters, the local medu al societies
could verv well be ot considerable help to
the workers' compensation agencies hy
analyzing the problems it is having vis u vis
workers' compensation and going directly to
the agency. Many stales do have advisory
coinmillet's that work with the compensa
tion agencies, but I would encourage you Io
do more than that, to actually visit the com
pensation agency personally. I realize that
physicians frequcntlv just don t have time to
lake off and go to the stale* c.ipitol. where the
workers' compensation agency may be lo
cated: but it is time well spent because* a lol
of the* complaints that come from the medi
cal profession result from a kick of unders
tanding of how that part icular workiTS com pensalion agency operates and how the laws
are implemented.
Next is <1 problem which very well may be a
sore spot to many of you and that s the need
for the compens.ilion agent y either Io lake
direct lestimonv or to lake depositions. Il has
been my experience lh.it many physicians
are reluctant to Like the time to engage in the
deposition-taking process or actually go Io
hearings. Now. there is no way of gelling
around the occasional incidents where then*
just has to lie .1 deposition or there has Io be
a hearing Then are some cases lh.it cannot
be resolved on an amicable basis. I would
like to point out to you. and I suspect most of
you know this that the great majority of
workers' compensation cases are not liti
gated cases Now the cases that give you
problems arc* those that have* sonic* sort of
nuance: those that take you out of your office*
Io go to the* trial deposition, or those that re
quire you to give disposition in your office.
But the* great majority, the* bulk of the
workers' cempensation cases, a.e not lili
gated but arc* handled bv medic al reports
alone, so it s important for you to under
stand first, th. type of medic al reports that
an* recpiircci This in and of itself fretpiently
can reduce* litigation Secondly, physicians
should try Io be as cdoperativc* as possible in
the liligative procc’ss. It has been my ex
perience that many of the* complaints that
arise from the medic al profession come
from a misunderstanding about the deposi
tion or the litigalive process. To prepare
yourself I would suggest that you talk to an
experienced physician or lawyer who has
bandied a lot of workers' compensation
cases or else talk directly to the compensa
tion agency. Know how the procedure goes.
P is essential that the physician, whether a
general pr.ictitioner or .1 specialist, be will
ing Io refer the patient Io a specialist if it ap
pears that there is a real need for it I know
this may sound rather elementary, and I
think most physicians do this, but occa
sionally you will run into a problem when* a
physician may be nerhaps the only practi
tioner in a given area, perhaps in a small
town, and it may bi* very difficult Io get that
patient referred Io a specialist. But my sug
gestion is that if you really feel there is a
n(M*d. and you're having difficulty in getting
the patient referred out or getting authoriza
tion from an insurance carrier, that you con
tact the workers' compensation agency and
try to explain why referral is necessary.
/Another thing which ! think is becoming
more important as the occupational ilisease
problem begins Io increase in workers' com
pensation is the need for physicians to un
derstand the local industrial hazards that
your patients an* exposed io. If then* is a
particular kind of plant in the area, where
most of your patients are going Io be work
ing. it would pat you to go out to that plant
and take a tour of it if you can possibly get
authorization and just learn as much as you
can about the particular hazards to whi( h
your patients will be exposed. This is going
to become more and mon* critical, as I say.
as the occupational disease problems in
crease. Something that I would like Io
emphasize again is the necessity for the
physician community Io understand what is
needed in the way of workers' compensa
tion medical reports. Now Ibis varies a great
deal from slate Io slate, and nearly every
agency has a particular form that they want
used or particular information that s critical
for their decision-making process, and frequenlly if these forms are filled out prop
erly. the agency can handle the case without
any litigation. But when the forms are poor,
when the physician is busy and just jots
down a few notes that seem to s. rve the pur
» (OMI'IAS\7H»X
pose for tne moment, there may be problems
later; am! consequently I would encourage
you. .I.- I mentioned a few minutes ago. to
find out directly from the workers' compen
sation agency what it is they want in the way
of a medical report. And also I would again
suggest to you that you try to look Io a physi
cian experienced in workers’ compensation
if you have access to one in your area, am!
let him toll you about the problems from his
perspective as one who has worked in the
field for some considerable period of time.
Emallv. I would like to encourage you as a
community of physicians Io be active in
workers compensation reform, particularly
in those matters relating Io the medical com
munity. such as making sure lh.it your stall*
law has full or unlimited medical coverage
Most stales today do have that, but there are
still <1 few that have some exemptions,
waivers, or provisions in the law which pre
vent complete medical coverage. Another
thing you need to pay attention to is the oc
cupational disease area. For many years it
was the well-known occupational diseases
like dermatitis, silicosis, and asbestosis that
were the ones that you heard about. With all
of the new chemicals that are being used you
can expect to see more and more cases of oc
cupational disease, and they are going to be
very ‘iifiicull for you to handle. .-\nd I would
stress again that you learn as much as you
WORM K »• « <>MP» ss \ nos
can about the occupational disease area, but
mainly that von be active in workers’ com
pensation reform matters, particularly those
matters which affedl your profession. One
which is vital Io you is the area of fees. Not
every state has a fee schedule. I think when
workers' compensation began, it was thigeneral practice that the various compensa
tion agencies had fee scheduh’s. Then we
began to grow away from this process, and
we got to the point where only a few slates
had a fee schedule. Now we n? seeing the fee
scheduk* come back into being again as
medical costs escalate. It may not be some
thing th.it you're interested in seeing J
returned, but it is something that very well
may return in many areas, and if it returns
or if you are in a slate where it's always been
active. I would suggest to you again that you
need to work with your stall? workers' com
pensation age’.cy to see that the fee
schedules are ri’asonable and are schedules
which comport with economic reality.
To conclude my comments this morning. I
can't emphasize enough the need to unders
tand how the workers’compensation agency
operates in your state, to understand its
laws, its nuances, its administrative pro
cedures. its forms. This is where a large per
centage of the problems exist. There are a lot
of complaints that are dm? Io plain old
fashioned mixups!
20
WHAT EVERY PHYSICIAN SHOULD
KNOW ABOUT RADIATION
PROBLEMS OF IONIZING
RADIATION
J. Ncwf'li Stannard. M.S.. Ph.D.
This presimtation will be concerned with
the so-called "high energy" radiations such
as X and gamma rays (photons), beta parti
cles (electrons), alpha particles (helium
nuclei), neutrons, and related particles.
Their mode of action differs markedly from
the actions of so-called non-ionizing radia
tions l?eing considered in other papers in
this session because they interact with
atoms, even the nuclei of atoms, and pro
duce ions directly or indirectly by the
deposition of energy in the KeV and MeV
range. These ions may have considerable
energy themselves and product! highly reac
tive free radicals in aqueous media or dis
rupt. by direct action, the atomic structure of
the material in which the energy is ab
sorbed. In contrast Io many other types of
radiation the absorption of high energy
radiations is relatively nonspt’cific. i.e.. it is
not greatly modified by the exact chemical
structure of the absorber. Direct ionization
occurs by interactions with matter of
charged particles having sufficient kinetic
energy to produce ionization by collision.
Indirect ionization occurs when uncharged
particles (or waves) liberate directly ioniz
ing particles by their interaction with atoms
or by initiation of nuclear transformations.
So much for definitions. The title for this
symposium has the phrase “What every
physician should know.- I wish devoutly
that it were possible to address this broad
subject fully, for I feel there is a small but
very significant body of facts and attitudes
‘.hat every physician should indeed know
about ionizing radiation. The average medi
cal school curriculum even today does a very
inadequate job of preparing the physician
for the role that he will inevitably have to
play in the nuclear age as counselor, consul
tant. advisor, and possibly as attending
physician. But this must be* detailed al
another lime and place, for there is too much
to say of direct pertinence to occupational
health.
RADIXIIOS
22
SOURCES OF IONIZING RADIATION
The largest single source of exposure to
ionizing radiation in the I’nilrd States is in
the medical and dental uses of X-rays and
radioisotopes This is because they are by
far the most numerous and most used
sources. Those occupational physicians who
have a sizeable medical department <ire un
doubtedly well aware of the concern in
organizi’d radiology and among radiation
protection specialists for reduction of unnecessa’A patient exposure and concomitant
fuller protection <4 radiologic al personni’l.
Anyone wishing farther details can consult
publications from HEW.’--’ the profession
itse!’?'1'7 and others.*”*’0 1 am happy to
stale that the adversary relationship that
developed some years ago bctwt'*n the
radiologists and those primarily concerned
with ladiation protection is gradually being
replaced by full cooperation and under
standing. The radiologists, medical and den
tal. ar.* now .akmg considerahde initiative in
policing them?el\es and their technical
staffs, and the latter also have their own pro
fessional (?rganizations and standards.
There is much yet to be accomplished. But
the occupation.d physician needs to be
deeply concerned about these matters only
if he has his own X-ray machine in the back
room and operates outside the circle of
organized radiology. In this case he should
look to assistance from state and local
authorities and from manufacturers of
machines and film for ways to detect and
eliminate any defects and to get the best
results with minimal exposure of patient
and personnel.
Those physicians who are connected with
large nu< tear energy establishments are
already fullv familiar with the variety of po
tential radiation sources present and have a
well-trained health physics or radiation pro
tection organization at their side in order to
meet licensing and other federal require
ments. What (toes need Io ee said here con
cerning the nuclear energy industry in rela
tion to the ordinary part- or full-time practi
tioner of occupational medicine is that he
should be more than a passive bystander
regarding the radiation problems potentially
associated with nuclear power operations.
2 I
As a member of a closely related facet of the
health industry, the occupational physician
is likely to be looked to for profession.il
judgment—even Io lend a hand in the event
of an emergency. H(* should be well ahead
of the layman in his knowledge of the
hazards involved and be neither blindly op
posed or sanguinely disinterested because
the chance of his needing to know anything
about nuclear power seems so very remote.
Again. 1 can only recommend that you make
it your business to read some of the more
objective literature on the subject” <213 u
and consider it in the same category a* a
brush-up in physiology or pathology.What
sources an* left, after medical and nuclear
energy installations, that should or could
concern the physician in part—or full-time
occupational health, and what is their sig
nificance? In terms if significance, they
constitute probably ten percent of the users
of radiation even in an industrial state.15 But
they are more likely than any other sources
to be in the hands of relatively untrained
personnel, to be difficult to supervise and
monitor because they are frerpiently operat
ing under mobile or field conditions or hid
den away in process lines. Thus, the occur
rence of accidental overexposures is quite
out of proportion to the relative numbers of
units in operation. For example, in Pennsyl
vania’5. non-medical analytical X-ray
machines with only 15(J facilities and 200
units out of over 10.000 users of radiation
sources in the state contributed all of the 22
reported cases of industrial X-ray radiation
injury requiring mi’dic.d attention in the
period 1957-1966. And four of the cases re
quired amputation of fingers! Hence the sig
nificance <;f your most likt’ly sourci’s is far
from trivial.
The primary source’s are the cabinet X-ray
machines used for non destructive testing
procedures or package examination,
electronic equipment used for similar pur
poses. X-ray diffraction equipment, analyti
cal X-ray equipment, neutron activation in
stallations for analytical purposes, neutron
sources used for oth(»r purposes, and
radiographic equipment using sealed
sources that contain radionuclides such as
c o b a 11 - 6 0. c e s i u m -1 3 7. i n d i u m -1 9 2 .
thulium -170. and radium-226 plus or minus
k xih .1
its decay products. Frequently weaker but
still significant sources are found in tbit kness gauges, in-process control and measur
ing devices for flowing liquids, height and
depth gauges for large, inaccessible con
tainers. luminous signs and buttons, static
eliminators, and the like. And we must not
forget ihat the laboratory is as likely to have
a potent radiation source lurking in an
analytical tool operated by persons
untrained in radiation protection as is the
remote field unit testing welds in a newly
laid pipeline.
Fortunately an excellent summary of both
the sources and what can he done about
• hem is contained in a symposium on Radia
tion Safety and Protection in Industrial Applications held in 1972 and a\ail.ible as a
DHFAV publication.”* r\ few new aspects
have been added since then but thev .ire pri
marily quantitative changes to higher
energies and more applications.’9 This, plus
the annual and speci.il' reports from the
Bureau of Radiological Health of FDA under
Public, Law 90-602—■The Radiation Control
for Health and Safety Act"—counterpart re
ports from OSHA and NIOSH. and in the
gene.'.il lit •rature.’"
provide excellent
covera.*..•• of the variety md relative* impor
tance if these many sources. Let it be
emph.isized ag.iin dial these sources .in* probahlv ’hi* most likely io he subject to acci
dental if isuse or misunderstanding of all the
extant radiation sources, and they fall
sepic.ri’ly .n the d. .nam of the occupational
health SC:eD’’st
CH/\RACTERISTICSOE THE SOURCES
Two broad (.ategorics exist:
1.
•>
P U)l \HO\
Those that exert their action
through highly penetrating ioniz
ing radiation from a fully con
tained source, termed external
radiation sources: and
Radioisotopes that enter the body
through inhalation, ingestion, or a
wound and ai I bv irradiation of
cells after deposition in the tissues
of the body The second calegorv is
frequentlv dubbed internal radia
tion or ‘internal emitters. ’
Most of th** sources of interest to you are ex
ternal radiation sources, even those containing large quantities of radioisotopes, since it
is the penetrating radiation from their <lt-ca\
in a sealed source that is used Similarly,
physician interest in neutron sources would
normally he as ext(*rnal radiation sources.
There an* a few procedures such as leak
testing with krypton, or the exposure of
miners to airborne radioactive dust, where
the normal exposure mode in industry is to
an internal emitter. But the primary com < rn
with internal emitters will he through the ac
cidental loss of radionuclide from a sup
posedly sealed source. In tin* case, tor exam
ple. of a multicurie Co-60 source, any signifi
cant leakage presents a major problem. But
even devic!*s such as static eliminators
luminous buttons, and so forth, ha'e la-en
the source of unexpected and sometimes
serious contamination incidents, because
they went undetected long enough to allow
much dispersion of the radioactive
materials. Fortunately these accidental
releases are infrequent. But the great
difference between the problems of external
and internal sources must be appreciated.
These* will be ( numerated later.
With any given type of ionizing radiation the
ability Io penetrate mailer depends stn»ng’\
upon the energy. The higher the energy, the
greater lh»‘ penetrating power with certain
constraints. Thus, industrial radiography
has advanced in pari by the development of
higher and higher energy sources. /Xiong
with this comes the need for greater shield
ing. greater distance between the operator
and source, and the application of image ’ntrnsifying and other means to compensate
for the increase in energy and to get the
operator away from the primary beam.
But another factor, termed radiation qmthly
plays an important role. The eleclrom.ig
netic radiations typical of X or gamma r e.s
do not collide with atoms or nuclei directly
and have very sparsely ionizing tracks e\( ep! al their very end Neutrons, alpha parti
des. and so forth have mudi more dense.y
ionizing tracks partly because of their
greater mass, partly because of the electrical
charge in the case of alpha particles, and
partly because they act by a different
mechanism. They lose their energy in a
much shorter track and thus have much less
penetrating power. Conversely, they deposit
a lot more of their energy in a small volume.
The result of this is that .in alpha particle
source external to the body is easily shielded
out by the thickness of the horny skin
epidermis or even a sheet of paper and is
thus relatively innocuous as an external
source. But because of the high density of
tracks produced, mon* accurately referred to
as a high Linear Energy Transfer rale (LET),
alpha particles can be very damaging if they
do enter the body and deposit in tissue. In
deed. it is generally considered that a cell
will almost certainly be killed by the traver
sal of a single alpha particle track through its
nucleus. The same distin ition applies to
heavy nuclei from other sources and to a
lesser degree to neutrons. Thus, the radia
tion quality (largely determined by the LET )
is as important, frequently more important,
than energy.
In radiation protection practice the impor
tance of radiation quality is accounted for by
the use of a practical number called the
■quality factor." The range of this is shown
in Table l.zu
PRACTICAL QUALH Y FACTORS
Rounded-QF
Radiation type
Xrays. gamma rays, electrons or positrons.
Energy >0.03 MeV
Electrons or positrons. Energy <0.03 MeV
Neutrons. Energy <10 KeV
Neutrons. Energy >10 KeV
Protons
Alpha particles
Fission fragments, recoil nuclei
1
1
3
10
1-10
1-20
20
Table 1. (Modified from Ref. 20)
The quality factor for neutrons is more de
pendent on energy than that of some other
radiations and ranges from about 2 to 11. but
this is detail beyond what every industrial
physician should know and I will not ex
pand upon the numbers here.
Finally, it should be emphasized that the
mechanisms of interactions of irradiation
with matter do not change whether the
source is external to or within the body. 1 he
same phenomena occur. As described
above, it is clear that a high LET radiation
that penetrates poorly from outside the body
can be very damaging once inside the body,
but this effect is due to a difference in loca
tion of the source rather than a difference in
mechanism. But still other major differences
exist between external and internal sources.
Usually the external source can be turned
off or shielded, a process whi< h is obviously
impossible once a radioelement is deposited
in cells or tissue. And finally the radioele
ment will be distributed (i.e.. metabolized)
in the body according to its chemistry. Thus,
it may be or become highly localized in cer
tain tissues such as bone, liver, lung, kidney,
portions of the reticulo endothelial system,
or even gonadal tissue. These variables
make the problem of internal dosimetry entiiely different and more complex than
those of external radiation. If you have an
incident involving internal contamination
and have not had experience with it. you
would do well to have some telephone num
hers for expert help readily a! hand.
BIOLOGICAL EFFECTS OF CONCERN
As with most toxic agents the effects depend
greatly on dose. At high radiation doses a
well-described symptom comph’x. termed
k XDM1IOS
25
the acute radiation syndrome, occurs. This
has been very completely described by
many2*-2- and can be found in most text
books of radiation biology2’ or radiation
protect ion.Briefly, it is characterized by
sudden onset of nausea and vomiting, diar
rhea. followed by precipitous decline of both
red and white cell counts, fluid loss, leaky
capillary mmnbranes. and al the very highesl doses, earlv and pronounced central ner-
vous system symptoms. Occupational physi
cians are unlikely to be involved in such an
acute incident but should be well aware of
what to look for and do. 1 especially recom
mend consulting the book by Saenger.21 At
lesser doses the changes are mon1 subtle
i nd take longer to develop. Table 2 presents
one of many summaries ol expected dose
effect relationships in man.25
REPRESENTATIVE DOSE-EFFECT RELATIONSHIPS
IN MAN FOR WHOLE BODY IRRADIATION
Nature of effect
Minimal dose detectable by chromosome analysis or other
specialized analyses, but not by hemogram
Minimal acute dose readily detectable in a specific individual
(e g. one who presents himself as a possible exposun1 case)
Minimal acute dose likely Io produce vomiting in about 10%
of people so exposed
Acute dose likely to produce transient disability and clear
hematological changes in a majority of people so exposed
Median lethal dose for single short exposure
Representative
absorbed dose
of whole-body
x or gamma
radiation (rads)
5-25
50-75
75-125
150-200
300
Tabb? 2. (Modified from Ref. 25)
There are many caveats foreven these num
bers. but they give some idea of the range
over which a physician might expect to see
something occur in an exposed individual
under his care.
Note ’hat the dost* m Table 2 is given as
whole -body dose r\ different pattern would
of course prevail for partial-body radiation
as you c in readily recognize. All of the num
bers in fable 2 are far above any accepted
level of occupational or population exposure
when i.unsidered as whole-body exposures.
They are pertinent here only in the event of
relatively ;ross overexposure. Nevertheless,
they .ire not without relevance to normal
operations in occupational medicine. While
gross oven xposure of the whole body is
unlikely without gross carelessness, acute
overexposure ol fingers, hands, or a
localized body area has quite a finite likeli
hood of occurring even in current practices.
Exposure Io the direct beam of intense
radiation from an X-ray diffraction or
analytical machine, or even a radiography
source cannot be ruled out: neither can the
unwitting manipulation of an exposed
sealed radioisotope source or the spread of
contamination from a leaking sourci*. In all
instances except the one of contamination.
one would look for some of the classical
signs of acute radiation exposure of the skin
such as skin erythema, inflammation, and
ulceration that will not respond to normal
therapeutic measures. (Recall that four of the
twenty-two reported o\erexposures in
Pennsylvania required amputation ol an ap
pendage. )
SKIN EFFECTS. SINGLE EXPOSURE
Early effect
Chronic effect
Chromosomal changes only.
None (Possible slight neoplastic
500 R
Transitory erythema. Tr msitory
alterations).
Usually none. Risk of altered function
2500 R
epilation.
Temporary ulceration. Permanent
increased.
Atrophy. Telangiectasis. Altered
5000 R
epilation.
Permanent ulceration (unless area
pigmentation.
Chronic ulcer, substantial risk of
very small).
Ordinarily necrotizing, but recovt?ry
possible when radiation has
carcinogenesis.
Permanent destruction to a depth
Exposure
50 R
50.000 R
dependimt upon radiation energy.
extremely low penetration.
Table 3. (Modified from Table 3. Rei 29)
EXAMPLES OF BIOLOGICAL RESPONSE
IN HUMAN ORGANS AFTER EXTERNAL
PARTIAL BODY IRRADIATION
Organ
Dost? schedule
Ovary
1500 rads/10 days
Testis
Single dose or
extrapolated
equivalent
RADS
200
000*
50
hoo*
200*
Rectum
1500 rads/IOdays
25-75 rails in each of 5-10 days
(Certain bone marrow segments
require higher doses.)
2000 rads/30 days
3000 rads/40days
1500 rads/20 days
2500 rads/30 days
3000 rads/30 days
4000 rads/42 days
5000 rads/30 days
0000 rads/42 days
4000 rads/30 days
6000 rads/56days
K000 ra<ls/56days
Bladder
10 000 tads/50 days
‘ 400*
I :r'‘ter
12.000 rads/Stidavs
4000*
Bone marrow
Kidney
Stomach
Liver
Brain and
spinal cord
Lung
Effect in relevant organs
Temporary amenorrhea, sterility
Permanent menopause, sterility
Temporary sterility
Permanent sterility
Hematopoiesis inhibited in irradiated
volume Usually compensated by
marrow acti . it\ in unexposed sites
Nephritis, hypertension
1000*
Atrophic mucosa, anacidity
1500'
I iepatitis
2200*
Necrosis, atrophy
2200*
Pneumonitis, fibrosis
27t .)*
Atrophy Limit of tolerance, most
cases
Atrophy. Limit of tolerance, most
cases
Atrophy. Limit of tolerance, most
cases
•Extrapolated equivalent calculated from the empirical relation D,. = Dot exp (-0.27). where D(. is the
extrapolated etinivalenl single dose, when an actual dose of D() is spread over the time ’ davs. I bis
relationship essenti.dly assumes an equal daily dose schedule. Other formulations (eg .the Ellis loimula 52) give successful empirical results for some erratic fractionation schedules. Such refinemerds
are not needed he.a; as in Table? 1 these entries are meant to be descriptive, rather than definitive.
Table 4 (From Ref 29)
k Uli tills
You would also look for s •me of the effects
of acute partial-body exposures (Table 4).29
Usually the circumstances can be
reconstructed sufficiently to get an idea of
probable dose. But again, unless one has hud
experience, he should not try to go it alone;
the smaller the operation, the more the need
to call in outside help.
By contrast to these early, relatively acute
effects, the long-term delayed effects of
ionizing radiation of concern are primarily
carcinogenesis in the case of the individual
and genetic effects in consideration of the
future of the human race. In the case of
genetic mutations, the effects may take
several generations to be expressed if they
happen to be recessives. Frequently car
cinogenesis has latent periods of twenty
years or more.
We have direct and convincing evidence
that ionizing radiation can cause cancer in
man. and we are even accumulating some
moderately satisfactory quantitative dose
effect relationships in the high dose realm.26
For genetic effects we must rely entirely on
data from animals, primarily the mouse.
Detection of radiation-induced mutations in
man. which are qualitatively identical to
those from other sources and those occur
ring spontaneously, is manifestly impossi
ble. But there is no reason to doubt that
radiation can produce genetic changes in
man. Thus, because of these long-term
effects and the current state of our
knowledge of the dose-response relation
ships. it has been necessary to exert great
caution in setting radiation exposure stan
dards and io be ultraconservative relative to
most if not all other agents. Useful and int jnlionally abbreviated summaries of both
the phenomena and of dose-effect relation
ships can be found in the textual references
already given and in the books by
Andrews27 and by Shapiro^
Despite their importance to the field of
radiation protection, these long-term effects
art! not something one can expect io identify
positively in the practice of occupational
medicine. They are statistical matters repreKADIATIOS
sentm.g a small increase of risk and are not
specifically or individually identifiable. This
leads to my final section, a consideration of
radiation protection standards.
BASIS FOR RADIATION PROTECTION
STANDARDS
Unless physicians are in a situation where
radiation sources are a very minor pari of
the operation, they have undoubtedly been
exposed to the presence of an array of state,
federal, and other standards governing tl.j
exposure of workers and of the population. 1
will not subject you to the numbers here, for
unless you are already familiar with dos ietry and unitage. the numbers them -Ives
have little meaning.
The basic philosophy of radiation protection
has been for years the avoidance of any and
all injury that would be unacceptable to the
individual in relation to other possible
hazards of living and/or employment, or that
would be judged by competent medical
authorities to be detrimental to the in
dividual or the race. This view still holds.
But a few years ago it was agreed that the
most conservative interpretation of the
probable dose-response* relationship is the
assumption that responses at low doses
should be extrapolated from higher doses by
assuming that a linear relationship holds
and that there is no dose threshold. While
acceptably conservative, this concept has the
corollary that any dose, however small, may
have some effect, however small. Thus,
/udgn.ent has to enter as to what constitu’es
an undesirable effect both qualitatively and
quantitatively. Also, the idea of not allowing
any effect (i.e.. risk of an effect) without
some corresponding benefit has been
superimposed on this first decisional pro
cess. and we have been treated to some
elegant charades balancing risk against
benefit. You can readily appreciate the
dilemma of deciding whose risk versus
whose benefit and the inevitable problems
of comparing such grossly dissimilar entities
in a population of workers, let alone in the
general population.
Application of the linear no-threshold hy2H
1
i
I
-1
I
i
potheses as a model can generate calcula
tions of numbers of excess cases of this or
th.it effect to be’ expected, and these include’
estimates of numbers of people killed m the
first or in subsequent generations. These
.-.alculations characteristu ally multiply s >me
very low- incidence rale by a large popula
tion theoretically receiving the dose (e.;>..
that of the* United Stales) and get startlingly
large figures. Sooner or later the fact that this
calculation was based on a model gels
forgotten and the numbers gel treated like
real deaths of real people. The cognizant na
tional and international bodies in the field of
radiation protection, such as ‘.he U.S \’ational Council on Radiation Protection and
Measurement (NCRP'l and the International
Commission on Ra'liidogical Protiction
(1CRP). are carefully examining and reex
amining all of the evidence I hey have yet to
be convinced ihal current standards are
seriously under-conservative, although cer
tain individual areas are dearly due for
some changes.
'
r
i
!
-J
Because industry has been able to operate
far below these general standards, it has
been convenient to add conservatism by the
admonition to design and operate at levels
"as low as practicable'' or ".is low as prac
ticably achievable." Indeed the U.S. federal
establishment finally yielded to pressure
from the engineers for numbers and staled
in the Code of Federal Regulations what the
"as low as practically achievable levels
should be for design criteria for light water
reactors In a sense, attaching ‘'f specific,
numbers is in direct contradiction to the as
low as practicably achievable " principle but
it had to De done.
data from the exposed Japanese. Quite ade
quate summaries of both phil'isoph,. and
data are available in the books by
Andrews27. Shapiro-”, and Morgan and
Turner^, and in the recent repoits of the
X’C.RP-*'which give much of the philoso
phy as well as the recommendations.
Lauriston Tayl<»r. President of NCRP has
slated eloquently on many occasrns. in
cluding his chapter in the volume or. Radia
tion Safety and Protection in Industrial Ap
plications already cited**, that the exercise of
judgment is the key ingredient in radiation
standard setting and evaluation. The stan
dards are already so low that no one will be
able to pick out a given individual and relate
his particular disease to exposure al or
below the level of the standards. The judg
ment must be made on a statisti<al basis
with many non-science elements. Fre
quently this exercise of judgment, much
al in Io what the physician calls clinical
judgment, seems to be submerg'.al in a
welter of numbers calculated in different
ways and for different purposes Indeed we
seem io be in serious danger of ovt r regula
tion al the expense of the exercise of profes
sional judgment This trend is unfortunate
for we have behind us in the radiation field
the largest body of information in a large
variety of life forms of any of the ’gents im
pinging on man and his . nvironme-it. I nis
is one fact I feel every physician should
know about radiation. We .ire not working
in the dark anything like to the extent w“ i
m many of the areas of chemical toxicology
and we should make full use of what we
have.
SI MM ARY
I
But this discussion is somewhat aside- from
the siandards applicable to occupational
medicine Ivpes of operation. 1 he current
basic standards of XU.RP. ICRP. the states,
and the federal establishment are those you
may need to be aware of. And these, while
appreciably lower than in the years pi'or o
the nuclear age. are still basically derived
from experience in medical installations, the
radium dial painters and patients, and re
lated more recent expoiiences including the
increasingly significant ar.cumulaiion of
Tins paper .emphasizes those aspects of
ionizing radiatio sources and effects mast
lik; l\ t<> impinge on the* practice’ at ’he fullor p.irt time occupational physic.tan iti an in
dustry where radiation source’s .ire ».r.l\ one
of ’he manv opc’ralions. It doe’s. howeveT.
admonish the1 o<. upational physic ian to be
cognizant of th«- mam fe.itures ot medical
radiation exposures since ihese constitute
the largest single source’ of man -m-..1e radia
tion e’xposure. He should also have some’
PUH KI tO\
29
j^gaBBao
knowledge of noclear energy installations
beyond what is availabh* in the popular
press. Leads are given to succinct yet inform.itive referenci1 material, and tht' need for
having sources of expert help available and
arranged for before an incident occurs is
emphasized.
Commerce of the U.S Si-natv I’ait I. Serial No. 90 49.
It is quite clc.ir lh.it there are some things the
occupational physician should know about
radialion primaril* because he is a physi
cian. other things because he is likely to en
counter some rather difficult situations in
practice dot' Io remoteness and mfrequimcy
of the operations and the higher likelihood
that the sources will reach untrained hands
than i; true of installations dealing primarily
or exclusively with radiation sources. It is
also emphasized that our radiation protec
tion standards for ionizing radiation, even
though there is much yet to learn, rest upon
essentially the largest body of scientific in
formation in either man or beast of all of the
potentially hazardous agents on the in
dustrial scene
beginning Jan 27. 1971
REFERENCES
Health in ()... up.iiion.il Medi< me Pr .ctic.e pp. 499-551
Occupational Meilici ie. Principles and Practical Ap
plications Year Book Medical Publishers. Chicago.
pp. 31«-4. GP(I. U ashingtun. DC. 19»>H.
lit. Health Physics in lh<
2. Gonad Dose ami Genetically Significant Dose
from D'agnostic Radiology. t'.S.. I9i»4 and 19.0 DHEW
of
IE Lapp. R E
The Four Big Fears AIhhiI Nuclear
Power." New York l imes F» l-ruary 7. 1971.
Lipp. R E Series id lout .11 til les m New Republic
13. p-rdan
Risks
Ptiy
.\m b ar Energy
II
s loday May Pt70
Bi nclits versus
14. Eorem.in. i> (ed i Nm le.ir Power anti the I’uldic
Univ. ’••Iiniiesut.i Pres-. 1970
15. Gerusky. i M
I1 he stairs
states Role in Industrial
Radiation 'salety Svnipo-iiiin
iiip<>'iii:i'. on
•»:i 1Ra.lia'mn Safety and
Piotei.tion in lndusiii.il App.n atu-ns. DHFAX publ No
FDr\ 73-BOi2. BRH DEP
3 1972
16. U.S Department of Health. Education, and
Welfare. Symposium on Radiation Safety am! Proleut on in Industrial .Applu atioiis DHF.W Publ. No FDA
Ul 8012 BRH DEP 7 « 3 1972
17. Wrenn. M<DE
and HF
Schulte
I. V
Craley
and P R Atkins teds) Ionizing Radiation pp 179-217.
Industrial Environmental Health Aca<*eini<. Press.
New Yor*. 19-t>
18 \uelz. GE
I. Reduction of K.uintion Dose tn Dugnostic X-r.>y
Proc
1972. DHE'A Pubi FDA 7.t 0029. 1973.
12
Procedures. DHE\\ Puhi No. EDA 73-rt<>09 1972.
Healing Arts
•lealth Physics Society Midyear Topical Symposium.
ami Carl Zetiz (ed». "Radiologic
1975.
19 Villiforth. |.C Symposium on R.idi.ition Safety
and Protection in lndustri.il /\pplic.itions." DHF.W
Puhi. No FDA7.iH(»!2 BRH.-DEP 73 3 19~2
Report FDA 7t> H0J4. 1'170.
20. Table 5. p H3 N.itiniiai Couni il on R.idiation Pro
3 Radiation Safety Handhixik for ionizing and Non
ionizing Radiation L'diEW Report FDA - o-rtOOS. 1970.
4
A Practical Manu.d on the Medical and Dental
Uses of X-rays with Control of Radiation Hazards. Am
College of Radiology. 195H.
5. How to Protect P.itient and Physician During Xray Examination Instalment 1 Effects of Radiation.
Installment 2. Responsible Use of Diagnostic X-rays.
Am Family Physmar.-GP 1(1)13. 1970 and l(2):105.
1970
6. Chamberlain RH "Medu al Rad.ation Perspec
tive in Risks an t Rewards Am | t »o Health 55:/20.
1905
tection ami Measurements tNCRPi Report No 39.
■ B.;sir: Radiation Protection Criteria
NCRP Publica
tions. P(>. Box 4Kt>-. Washington Du 20U0H. 1971.
21. Saenger. E I. (ed ) "Medn al /Xspects of R.nlialion
Ai.i.idents. A Handbook for Physii lans. Health
Physicists anil Industrial Hygienists. U S AEG. Con
tract A 1'130-1) 210i> 19C-3 Superintendent of Ducu
menis. Washington. D.(... 1903
22. Hemplen..inn I. II . II Lisco, and | G. Hoffman,
■'rhe /Xcule d.uli.ituui Syndrome A Study of Nine
Cases and A Rev tew «d th- Problem Ann intern Med
.if- 2H0 510. 1952
23. (.asarett. -\ P
Radiation Biology
Common (’.auses of Ex. t ssive Patient
Exposurr in D’agnostic Radiology' New Eng | Med
271. HH4 I9C4
Im... Englewood ( lifts \|
H Morgan. K Z ’ /Xdequai y of Present Standards of
Radiation Exposure
Envinmmental anil Ecological
Forum 104. |ai uaty 1971. USAEC. Office of Inform.!-
Ilunlmglon. N Y
-
Blatz. H
non Services. 1972
9 Murjj.in. k Z Hr.irings before she Committee on
R \lll XTIOS
Prenln.e-1 i.dl.
l9t.H
24. Morgan. KZ and | F
lurner Principles of
Radiation Protri tmn Robert E Krieger Publishing C.o .
1973
25. Table 1 from N( KF Report 39 Basic Radiation
Protection Criteria
National ( oum il on Radiation
Protection and Measurements NCRP Publirntions.
PO. Box 480" W.ishimton. DC 20008. 1971
26 NCRP Report No. 43. "Review of the Current
Siale ol Radiation Protection Philosophy." National
Conned on Radiation Protection and Measurements.
Washington. D C. NCRP Publications. P.O. Bo* 4867.
Washington. D C. 20008. 1975.
27. Andrews. Hl. Radiation Biophysics. 2nd Ed.
Prentice- Hall. Englewood Cliffs. NJ.. 1974
31
28. Shapiro. J. Radiation Protection. A Cuide for
Scientists and Physic.ans. Harvard University Press.
Cambridge. Mass.. 1972.
29. NCRI Report 39. "Basic Radiation Protection Cri" r^oonal Council on Radiation Protection and
Measurements. NCRP Publications. ?.O. Bo* 4867.
Washington, D C. 20008. 1974.
RAZHATIOS
ELECTROMAGNETIC RADIATION
To provide a basis for understanding the
biologic effects of radiation, a review of
some fundamental aspects of electromag
netic (EM) energy is indicated. Strictly
speaking, the EM spectrum comprises all
energy that may propagate electromagnetically in space, and hence includes low
frequencies, such as 50 Hz and 60 Hz used
for power line transmission, radio frequen
cies. infrared through visible to ultraviolet
light. X-rays. Gamma rays, and Cosmic rays.
RADIATION
AND
OCCUPATIONAL HEALTH
Sol M. Michoelson, D. V.M.
The energies of the EM spectrum are prop
agated in the form of waves that act as small
bundles of energy called photons or quanta.
The energies residing in these photons (E)
nr** directly proportional Io the frequency
(V) of oscillation of the specific electromag
netic radiation associated with them bv the
formula E = hV. where h is Planck’s cons
tant. The photon energy measured in
electron volts (eV) and the frequency of an
electromagnetic wave is inversely propor
tional to its wavelength. The longer the
wavelength, the lower is the photon energy:
the shorter the wavelength, the higher the
photon energy.
Eor theoretical and practical convenience,
the EM spectrum is divided into two
subspectra according to whether or no* the
radiation involved is of a wavelength shork r
than or longer than that required to produce
ionization, which is in the X-ray region.
Radiation at wave lengths shorter than this
ionization wavelength are in the ionizing
radiation spectrum: those longer are in ‘he
non-ionizing radiation (NIR) spectrum. For
practical purposes, the NIR spectrum is
further divided into three sub-spectra,
historically termed optical, radiofrequency,
and electrical. Although th<?y coalesce, these
spectra are technologically different
The electrical spectrum is that in which
energy is usually transmitted by win’s or ca-
hies. By far. the greatest part of the man
made EM energy is m this spectrum, as 25
Hz. 50 Hz and 00 Hz electric power genera
tion. transmission, and utilization. Ihe
electrical spectrum also covers the bulk of
electronic devices, from control mechan
isms to audio amplifiers. Us upper limit is
traditionally a bit above the upper limit >f
human hearing, or about 20 kHz. Frequen
cies in this spectrum may. of course, radiate
and hence propagate in space as do higherfrequency EM waves.
The radiofrequ mcv spectrum, which is now
a misnomer because it includes frequencies
both below and above those of traditional
radio, is that in which energy usually is
caused Io travel in space and is geniT.ited.
directed, contained, detected, or utilized by
electrical or electronic me.ms II is con
sidered to extend from 10 KhZKkHz (very
low frequency—VLFI to 300.000 MHz (extra
high frequency—EHF). On an operational
basis, frequencies in the region from 100
MHz to 300.000 MHz (300 GHz) are desig
naled as microwaves.
The optical spectrum is that in which energy
traditionally is associated with light or its
neighboring radiations in the* spectrum and
is generated, focused, contained, delected,
and utilized by optical means. Recently, the
optical spectrum has been invaded by light(‘milting diodes and lasers (an acronym for
Light Amplification by Stimulated Emission
of Radiation). Bui since even these devices
rely mostly on optical techniques for then
effective utilization, they still belong in the
electrons, and produce ion pairs. Ihe
minimum photon energy c.ipable of produc
ing ionization tn water and atomic oxygen,
liydrogen. nitrogen, and carbon is between
12 and 15 electron volts (eV). Inasmuch as
these atoms constitute the basic elements ot
living tissue. 12 eV may be considered the
lower limit for ionization in b’ological
systems. Since the energy value of 1 quan
tum of non-ionizing radiation (NIR) is con
siderably less than 12 eV. the type of
electronic excitation necessary for ioniza
tion is no! possible no matter how many
rpiant i arc absorbed NIR absorbed into the
molecule either affects Ihe electronic energy
levels of its atoms, or changes the rotational,
vibrational, and transitional energies of the
molecules. Changes are produced in biologi
cal systems through either photochemical
(ultraviolet) and/or thermal modes (in
frared. microwaves).
Ultraviolet (UV) For the purpose of assess
ing ihe biological effects of ultraviolet (UV)
radiation, the wavelength range of interest
can be restricted to 100-400 nm.’ This range
♦‘xtends from the Vacuum UV (100 nm) to
the near UV (400 nm). The photon energy
r.mge for wavelengths between 100 nm and
400 nm is 12.4 to 3.1 electron volts respecli\ely.
MECHANISMS OF ACTION
The biological action spectrum for erythema
produced by IiV^radiation of the skin has
been the subject of investigation for many
vears. The most recent data show that a
maximum erythem.d effect is produced at
26f) nm with the secondary peak .it approx
imately 290 nm. The critical organs are the
skin and eyes, and UV irradiation results in
erythema, skin cancer, photosensitization,
and keratoconjunctivitis.
11 has been determined lhal one ionization
occurs on the a-, erage for every 34 eV of
energy expended in air. I hi1 actual amount
of energy needful to eject an electron from a
molecule (ionization potential) ranges from
10 to 25 eV. The extra energy lhal is ex
pended is used for exc.itation of molecules.
While whole-body exposure to I'V is possi
ble. common articles of clothing are effec
tively opatpie Io ultraviolet. Skin cancer has
been reported in workers exposed Io in
dustrial IIV sources^ ’•< or whose occupation
re(|uires them Io be exposed to sunlight for
long periods of time.
As an EM frequency decreases, (he energy
of the emitted photons is insufficient, under
normal circumstances, to dislodge orbital
Excessive UV (200 nm-4()0 nrn) exposure
produces photophobia accompanied by red
ness. tearing, conjunctival discharge, sur-
optical spectrum.
k \ni \ nos
:«3
face exfoliation, and stromal haze. Damage
to the corneal epithelium by absorption of
UV probably results horn photochemical
denaturation of proteins or other important
molecules in the cells, such as desoxy
ribonucleic acids (DNA) and ribonucleic
acids (R\A). The absorption is probably by
selective sensitive portions of single cells.
Visible light The hazards to man from visi
ble light ar»* relatively few and mostly come
from artificial sources such as lasers and
certain high intensity lights. The penetrating
ability of visible light is slight except for
transparent materials such as the lens and
humors of the eye. Light entering the eye
from a bright source is focused on the retina
and. therefore, the thermal irradiance is in
dependent of the inverse square law for im
age sizes greater than the diffraction limit.5
Because of its narrow depth of penetration,
visible I’ght in general does not manifest it
self as a potential hazard. There are situa
tions. however, in which it can become
hazardous. Epileptiform responses have
been produced in animals and children ex
posed to pulsating light near the alpha
rhythm frequence of the EEG.
Normally intense and blight sunlight
causes maximal constriction of the pupil
that the:by reduces the energy density on
the retina. Bright sunlight, furthermore,
causes painful photophobia that will not
permit prolonged direct and fixed observa
tion of the sun. The lid reflex (approx
imately 150 ms) is another mechanism that
protects the eye. The continuous action of
these measures would be adequate under
normal conditions to avoid burn injuries to
the retina.6
Infrared energy Infrared (IR) extends
from beyond the red end of the visible por
tion of the KM spectrum (750 nm) to about
lxlOG nn:. The IR spectrum is frequently ar
bitrarily divided into three bands: the near
IR (750-3000 nm). the middle IR (3xl03 3x104 nm) and the far IR (3xl04 to approx
imately lx IO6 nm).
There is little evidence that photons in the IR
(i.e . less than 1.5 eV) are capable of entering
into photochemical reactions in biological
systems, because they are too low in energy
to affect the electron energy levels of these
atoms, rhe interaction that dot s occur upon
absorption involves an increase in the
kinetic energy of the system that produces a
degradation of the radiant energy to heat.7
The most prominent direct effects of low
wavelength IR on the skin include acute skin
burn, increased vasodilation of the capillary
beds, and an increased pigmentation that
can persist for long periods of time. Under
conditions of continuous exposure to high
intensities of IR. the erythematous ap
pearance due to vasodilation may become
permanent. Many factors mediate the ability
to produce actual skin bum. aril it is evident
that for this immediate effect, the rate at
which the temperature of the skin is permit
ted to increase is of prime importance.7
Laser There are several mechai.^—.s in
volved in producing a laser lesion. The in
itial physical trauma is followed by the
biological reaction of the tissue itself. The
types of physical irauma may differ, but
only a few types of physical insults- may call
forth identical physiological reactions from
the tissue. This lends to mask the different
physical causations.«
There may also be amplifying factors in the
biological reactions to physical trauma.
These include reactions to thermally
denatured protein or other parts of injured
cells, and increased cellular activity from in
creased tissue temperatures accompanied
by diminished cell survival. In the case of
the photoreceptors themselves, the stimula
tion by light itself may cause a similar in
crease in metabolic rate. This deleterious
effect of the light may synergize with a simi
lar effect from an elevation of temperature.®
One important interaction of a laser beam
with tissue is denaturation of protein, the
extent of which is related to the incident
energy or power per unit area and duration
of exposure. The potential for injury to
tissues also depends on the ’■accessibility
of the tissue to the radiation, which in turn is
a function of the depth or penetration of the
34
R WMI'GS
uteto .an
radiant energy. When laser radiation im
pinges on tissue, the absorbed energy pro
duces heat. Rapid and localized absorption
may product* enough high temperalun? Io
boil the tissue water. The resultant steam
production can disrupt cells or even produce
dangerous pressure changes in an enclosed
and completely filled volume such as the eye
or skull.9
Photochemical reactions result in activation
of molecules by the capture of quanta of
energy. Such capture c »nstitut<*s the primary
• nt in a photohemical reaction. Some of
the photochemical reactions induced by
laser exposure may be abnormal, or exag
gerations of n< rmal processes.9
The primary hazard from laser radiation is
exposure of the eye. Exposure levels, if kept
below those damaging to the eye. will not
harm other tissues and organs of the body.
The type of damage inflicted on the eye by
laser beams ranges from‘a small and incon
sequential retinal burn in the periphery of
the fundus, to si'vere damage of the macular
area, with consequent loss of visual acuity,
up to massive hemorrhage a i I extrusion of
tissue into the vitreous humor, with possible
loss of the entire eye.“» Ixmg-term exposure
of the retina to wavelengths in the visible
spectrum, at levels not far below the burn
threshold, may cause irreversible effects.
The large skin surface makes this tissue
readily available to accidental and repeated
exposures to laser energies. The biological
significance of exposure of the skin to lasers
operating in the visible and IR regions is
considerably less than exposure of the eye
since skin damage is usually reparable or
reversible. Effects may vary from a mild
erythema to blisters and charring. Depig
mentation of the skin, ulceration and scar
ring and damage Io underlying organs may
occur from extremely high powered laser
sources.
One cannot discuss potential hazards from
laser eucrgiwithout mentionin'’ opera
tionally associated hazards such as com
pressed gases, cryogenic liquids, ionizing
radiation that may emanate from laser
Microwave Of the various NIR energies,
the RF and the microwave bands have
elicited the greatest interest and concern as
well as confusion in consideration of the
real and substantiated effects vis-o-vis un
substantiated or speculative effects.
Microwave wav<‘l(^ngths vary from abor.t 10
met(‘rs to about one millimeter in the fre
quency range of 30 MHz io 300 GHz. the
ANSI and OSHA standards, however,
define the micro wave range as 10 MHz io
100 GHz. The region between 10 MHz and
the infrared is generally .eferred to as the
RF. or radiofrequency, region. Certain
bands of microwave frequencies have net n
assigned lt‘tter designations by industry:
other, notably the ISM (Industrial. Scientific.
Medical) frequencies have been assigned ii\
the Federal (.Communications Cnmmisjuon
for industrial, scientific, and medical ap
plications.!
The basic biological effects of microw-ves
occur in the presence of significant t?mperature rise in biological tissue. Such
effects require exposure to relatively high
levels of radiation intensity and a suhsk fi
lial exposure duration. Levels of microw ave
radiation are measured as power densities
and usually expressed in terms of milliwatts/centimeter squared (i.e.. m\V/cm-). 1 o get
some perspective one can refer to the condi
tions of microwave diathermy where
moderate beneficial heating of a limited part
of the body is produced by exposure tn
about 1G0-500 mW/cm^ for 10-20 minutes.
At high microwave frequencies, well above
the usual heating frequencies, the radiation
is absorbed almost completely in the skin
just as with infrared radiation, and produces
heating of the skin. These frequencies are
felt in several seconds at exposure levels of
a few mW7cm2. At the heating frequencies
(ISM bands-918. 2450 MHz) the penetration
is a rew centimeters. At 2450 MHz
r xniMiov
35
**
t
power supplies and components, and iovc
materials used in laser targets or lasesystem elements. Adequate ventilation
should be provided to eliminate ot reduce
exposure to toxic materials.9
microwave exposure is sensed .it levels of
20-50 mW/cm- in a few seconds Al lower
frequencies, like those of television broad
cast. penetration and deep heating both in
crease?. At still lower frequencies the body
shunts out or reflects the field so that less
heating results even though the internal
field is fairly uniform throughout the body.
Injury from microwaves can be in the form
of burns. /Ml the scientific evidence ind:
cates that exposure creator than 100
mVV/cm- and extended duration (many
minute's) is required to produce such ther
mal damage*.
At an exposure level ten limes smaller, such
heating may still be felt but is not hazardous.
Al still lower levt'ls the radiation is not f<*lt.
Low levels of microwave radiation in the
form of broadcast television radiation con
tinually pass through our bodies. These
levels approach 1/1(10 of heating levels in
('lass /X reception areas and even closely ap
proach healing levels (e.g . ImW/cm2) in
certain high buildings or high terrain in the
vicinity of television towers.
Electrical, magnetic, and ele'Ctromagnetic
fields of sufficient intensity to interfere? with
noncompetitive? pacemaker function are? no!
uncommon. Yet fe*w patiemts notice? inter
ference' phenomem.i. and ewen fewer are? ad
versely affee.te’d. Al the* present stale of the
pacemaker art. the? probability of inlerference-indneed distress is very low
be’cause two unlikely events must eiccur
simultane-ously. First, the* pacemake’r must
misbe’have* rather dramatically. Se?cond. the;
•patient must remain in ’he field for a signifi
cant period, an unlikely situation because?
most inte’rfe’rence* generators have* an effec
tive* range of less than 1 fool.
PROTECTION GUIDES AND
STANDARDS
Ultraviolet In 1948. the Council on Physi
cal Medicine of the American Medical Asso
ciation issued criteria for safe exposure to
radiant energy from UV germicidal lamps.
This group recommended that for the pri
marily used wavelength. 253.7 nm. ex
pose res should not exceed 0.5/x W/cm^ for
periods less than 7 hours. norO. l/x W/cm2 in
the case of continuous exposure.
Electromagnetic interference Implant
electronic cardi.ic pacemakers, without
shielding or filtering, have been reported to
suffer interference from auto and lawn
mower ignition noise, electric shavers,
electrical hobby devices like Tesla coils,
microwave ovens, amateur radio transmit
ters. broadcast television transmitters and
radar transmitters. The U.S. Department of
HEW has recognized that the problem is in
pacemaker susceptibility and advised
against the generalized use of warning signs
around transmitters The medical profes
sion in the USA believes that the pacemaker
interference problem is not significant
clinically and feels that there is no great
danger to pacem.iker patients in today’s
electromagnetic environment.
Infrared Protection guides for IR exposure
are designed primarily for protection against
ccular effects Thfv main difficulty, however,
in devising protection standards against JRinduced cataracts is to correlate the informa
tion on the radiation emitted during in
dustrial processes with cataract formation.
The intensities of IR that cause cataract are
unknown. Only a small amount of experi
mentation on animals has been done, but it
has provided some knowledge of the way
cataracts an* formed: the* numerical data ob
tained cannot be used in devising standards,
due to the relatively massive and frequent
exposures used in experiments, and possi
ble physiologic.il and anatomical differences
in rabbit and human eyc*s.
The* most se*rious potential source's of inter
ference to sensitive* pacemakers .ire those’ of
powerful transmitters where a person re
mains in <i strong fie’ld. Newer pacemake’r
models are immune* Io most interference?
sources.
Infrare'd^j-afiiation can be* a problem in
whoI7"-Loelv heating, particularly in some in
dustries. such as ste*el and aluminum.
Although then* an* no specific regulations
currently, there has been a considerable?
effort Io develop a heat stress standard at the?
R WIHTIOS
federal level, and there has actually been a
NIOSH criteria document published on the
subject. It proposed to measure the wet
bulb-globe temperature (WBGT). which
quantity is subject to radiant heat load, in
addition to dry bulb temperature, humidity,
and air velocity. Considerable ■heat” has
been generated over the heal stress docu
ment. and there is much sentiment that such
a sweeping regulation :s not really necess
ary.
The American Conference of Governmental
Industrial Hygienists (ACGIH) has pro
posed threshold limit values for heat stress.
These Threshold Limit Values (TLV) refer to
heat stress conditions to which it is believed
that nearly all workers may bt? repeatedly
exposed without adverse health effects. The
TLVs are based on the assumption that
nearly all acclimatized, fully clothed
workers with adequate water and salt intake
should be able to function effectively under
the given working conditions without ex
ceeding a deep body temperature of 38°C.
Laser For the past several years, federal
agencies have been taking an increased in
terest in laser safety. Attention is focused on
protecting the user from eye and skin
damage. Bureau of Radiological Health
regulations apply to laser pr«v nets sold to
end users by laser manufacturers. The
regulation places requirements on manufac
turers only not users. Component lasers
sold ‘o Original Equipment Manufacturers
(OEMs) are not covered by these regula
tions. However, the OEM who incorporates
these lasers into systems that are ultimately
sold to end users must ensure that the
system does comply with the regulations.
All laser products are divided into four
classes. The power limits of each class are
detimined by the associated degree of risk
of biological damage from exposure to laser
radiation. Classes witii higher risk have the
most stringent safety requirements. The
regulations also include a precise pi-./cedure
for measuring power levels to determine the
laser’s class.
Class I limits laser power to levels at which
37
no evidence of biological damage has been
established. Class II to levels at which t?ye
damage is possible from chronic exposure,
and Class III to levels al which biological
damage to human tissue is possible from
acute direct exposure. Class IV includes,the
laser power levels at which biological
damage is possible from acute direct or
diffuse exposure.
The regulations that an? being developed by
the Occupational Safety and Health Admin
istration (OSHA) will be more significant to
the laser user than those established bv BRH
since the former will be directed at the j
operator of lasers. It is expected that these
will be completed this year. In addition, both
the American National Standards Institute
(ANSI) and the American Conference of
Governmental Industrial Hygienists
(ACGIH) have prepared regulations that
may apply to particular groups of laser
users.
Microwaves/jadiofrequcncy The standard
used in the U.S. and most Western countries
is that recommended by the American Na
tional Standards Institute (ANSI). The stan
dard specifies to personnel the maximum
microw.ave exposure to which they should
subject themselves. This exposure is charac
terized bv incident power density at the
location of personnel and by exposure dura
tion. The standard specifies safe unlimited
duration whole-body exposure up to 10
mW/cm2 or a maximum energy density ex
posure of 1 mW-hour/cm2 in any 0.1 hour
period. This standard is believed to bt? at
least a factor of ten below damaging levels.
Exposure power densities are readily
measurable today by hand-held survey
probes that are commercially available.
These survey instruments can read levels
between 0.01 to 100 mW/cm2. They use an
tenna pickups and sensors such as ther
mocouples for generation of current that is
amplified and read out on a meter scale as
mW/cm2.
Microwave emission standards have been
promulgated and specify the maximum
leakage level close to the external surface of
RAJHATIOV
equipment. It is the responsibility of the
manufacturer to meet such standards. It is
also important not to confuse (’mission and
personnel exposure standards. In general,
emission standards are far more conserva
tive than exposure standards in that for a
given emission level the potential exposure
level decreases rapidly with distance from
the point of leakage.
For a small leakage source, such as is
typically found along a door seal of a
microwave oven, the leakage level (in
mW/cm^) decreases approximately as the
inverse-square law of distance from the
leakage source. Thus, a leakage level of
several mW/cm2 at 5.0 cm from a device
produces exposure levels of only about 0.01
mW/cm2 ;,l 3-4 feet from the leakage point.
Emission standards applicable to
microwave ovens exist as federal regula
tions in the U.S. and Canada. The standard
in the U.S. specifies a maximum emission
level of 1 mW/cm2 (at 5.0 cm) before
purchase and 5.0 mW/cm2 (at 5.0 cm)
thereafter when the oven is operated with a
275 mi water load. In Canada the federal
standard sets a maximum leakage of 1
mW/cm2 (at 5.0 cm) when the oven is oper
ated with a minimum load specified by the
manufacturer. The Canadian standard also
applies to microwave industrial equipment.
PROTECTION STANDARDS—
PHILOSOPHY
In many areas of the industrial environment
there is considerable divergence in stan
dards used in Western countries in contrast
to those adopted in the USSR and other East
European countries. In any discussion of
protection standards in the USSR, the recent
publication by Glass" (1975) should be con
sidered. Although this report deals with the
concepts and principles applied to research
and standards setting for air pollutants,
these same criteria are applied to other
chemical and physical agents in the environ
ment. In general. Soviet standards are more
numerous and generally more stringent
than their American equivalents. This
reflects differences in the concept of an en-
vironmental standard, the research applied
to setting this norm, and the vigor with
which the standard is enforced.
In theory, the Soviet government feels that a
healthy environment can be preserved over
the interest of individual polluters; that
regulatory control over government en
terprise should be eas'ci to exercise: and
that the results of government-funded
research however tentative, should be enfor
ceable as law.12 In practice, attaining these
ideals is substantially more difficult m
achieve.1*
Marxist science emphasizes the close tie bet
ween research and the solution of practical
problems.13 Duplication of scientific effort
within the USSR is prevented, a policy that
may result in insufficient verification of
otherwise controversial results.11 From
research on standards to the practice of en
vironmental regulation, the physician is the
central figure, and all other scientists,
feldshers, and engineers are auxiliary. The
bias created by this dependence on physi
cians is evident in every phase of environ
mental health research and practice."
The Ministry of Health of the USSR 'S
responsible for planning and promotin;.
research on new pollutants, translating
these results into national standards, and
ensuring the enforcement of these max
imum allowable concentrations (MAGs)
The Soviet approach to standard setting is
straightforward. The MAC (maximum
allowable concentration) is defined as that
concentration of a chemical that at intermit
tent or continuous exposure provokes
neither disease nor reversible changes in the
adaptive physiological mechanism of the
organism acutely, in later life, or in future
generations.15 Soviet research in standard
setting for air pollutants is based on the
work and philosophy of V. A. Ryazanov’s
who felt that any chemical exposure that
produced a measurable change in anv
biologic function, even if fully reversible,
does not represent the optimum condition
for human existence and should not he permitled by the government or tolerated by the
people. The MAC is based on research to es3P.
RAf»ATI(»V
tablish the threshold effect level of a sub
stance. Since the standard reflects this
threshold of the lowest measurable effect, a
revision of the standard will usually make
the MAC even lower.”
Environmental standards are based on
research in health effects alone, without
regard to considerations of available control
technology, economic feasibility, or the
ability to measure adequately these levels in
practice. When a MAU. is currently unat
tainable. it should represent a direction for
future enforcement or a guideline for future
research in control technology. Research on
new standards follows
protocol estab
lished by Ryazanov. A "one exposure" or
’‘short-term’’ standai i is based on the
threshold’s of sensory stimulation in man
(e.g.. smell or taste), central nervous system
sensitivity (e.g.. electroencephalogram, con
ditioned reflexes), and reflex responses
(e.g.. changes in heart rate, respiratory rate,
or blood pressure). The lowest concentra
tion that can evoke some measurable change
in these tests is proposed as the level for the
short-term standard. The ‘long-term’’ or
”24-hour" standard is based on long term
toxicologic experiments on animals, and the
most sensitive indicator of a biologic change
is accepted as important. These long-term
standards are not monitored routinely in
practice.
Much Soviet research on environmental
standards may not be applicable to the West
because their interest is in determining only
the lowest concentrations producing a
measurable biological change, regardless of
its importance.” Full enforcement of pre
sent standards in the USSR remains an im
possible task because these standards are
numerous and in most cases extraordinarily
stringent.”
One can draw a most interesting contrast
with the United States in terms of the rela
tive importance of research and practice. In
the Soviet Union, environmental research is
programmed, traditional, and d:r-ctrd
toward determining no-effect thresholds.
Nonetheless, standards are adopted rapidly
and enforcement can be quite powerful.
39
carrying the full backing of the government.
In the United States the research effort is
very creative, open-ended, interested in
mechanisms of actions, and standards de
pend extensively on research from other
scientific disciplines?*
REFERENCES
1. \\ likening. G.M. 'Non-Ionizing Radiation." The
Industrial Environment—Its Evaluation and Control,
pp 357-376. U.S. Drpt. HEW. PHS. Center for Disease
Control. MOSH. Washington. D.C.. 1973.
2. Emmett. E A "Ultraviolet Radiation as a Cause of
Skin Tumors. ’ CRC Critical Reviews in Toxicology.
September 1973
3 Emmett. E.A. "Occupational Skin Cancer: A
Review. |OM 17:44-49. 1975.
4. Emmett. E.A. and S.W. Hurstman Factors In
fluencing the Output of Ultraviolet Radiation During
Welding " JOM. 18:41-44. 1976.
5. Buettner. K and H.W. Rose. "Eye Hazards from an
Atomic Bomb." Sight Saving Rev. 23:194-197. 1953.
6. Geeraets. W.J Radiation Effects on the Eye." in
dust. Med. 39:441-450. 1970.
". Mateisky. I. L V. Cralley and G.D. Clayton (eds.)
'Non-ionizing Radiations.' Indus Hyg Highlights Vol.
1. pp. 140-179. Industrial Hygiene Foundation of
V.i.Tica. Inc.. Pittsburgh. 196H.
8. Wolbarsht. M.D. and D.H. Sliney The Formula
tion of Protection Standardsdor Lasers." Laser Applica
tions in Medicine and Biology. Vol. II. Plenum. New
York.1974.
9. Goldman. L.. W Kapuscinska-Czerska. S.M.
Michaelson. R.J. Rockwell. D H Sliney. B. Tengroth.
and M. V.olbarst. Health Aspects of Optical Radiation
With Particular Reference to Lasers." Manual on Nonloni ing Radiation Protection to be published by World
Health Organization.
in Curtin. T.L. and D.G. Boyden. "Reflected Laser
Beam Causing Accidental Burn «.f Retina." Amer J
Oph'hal. 65:188-189. 1968.
11 Glass. R.l. “A Perspective on Environmental
Health in the USSR Research and Practice." Arch En
viron Health 30:391 1975.
12 Goldman. M l. The Spoils of Progress. Environ
mental Pollution in the Soviet Union. Ml F Press.
Cambridge. Mass . 1972.
13. Zaleski. E. "Central Planning of Research and
Development in the Soviet Union Science Policy in
the USSR. Committee for Science Policy Organization
of Economic. Cooperation and Development. SP (68) 5
Scale Z. 2 July. pt. 1. Paris. 1968.
RMH\TIO\
V.. kmerov. NJ. “Centro! of Air Pollution in the
USSR." WHO Public Health Papers, No. 54.. Geneva.
1977.
15. Sanotskii. I.V. “Strategy for the Investigation of
New Substances to Establish Their Safe Permissible
Levels: Criteria for Harmful Action.” WHO Consulta
tion on Methods Used in the USSR for Establishing
RAPMTfON
Biologically Safe Levels of Toxic Substances. WHO No
3636A. pg. 7. Moscow. Dec. 12-19. 1972.
lb. Chizhikov. V A. “Methods of Determining the
Maximum Allowable (Concentrations of Atmospheric
Pollution." WHO Interregional Travelling Seminar on
Air Pollution. USSR Ministry of Public Health
CIFAMS. Moscow. 1967.
40
GENERAL COMMENTS
OCCUPATIONAL HAZARDS
FROM NON-IONIZING
RADIATION
'FhomasS. Ely. M.D.
You have heard some background informa
tion on non-ionizing radiation hazards. I am
going to carry this along with some brief
thoughts about putting the information into
practice in the kind of preventive medicine
we call occupational medicine. The develop
ment of scientific information from basic
research is essential in the control of oc
cupational hazards, but it is only the first
step in a sequence of activities that is neces
sary in this control. The information needed
for control purposes must evolve through
several stages including basic research, ap
plied research, and the development of a
consensus position leading to a practical
standard. This may then evolve into a practi
cal regulation. It is a fad of life that a regula
tion is often necessary Io accomplish control
that a consensus standard could not.
It would be as wrong to use the techniques
of basic research to achieve control as it
would be to use the techniques of control to
conduct basic research. In basic research
on«* strives for extensive and accurate data.
For control purposes, such would almost al
ways be impractical and unnecessary. I have
frequently responded to proposed federal
regulations requiring 5°o accuracy with the
comment that 20 or 25% should be plenty
good enough. Factor-of-two accuracy is
usuallv sufficient for control purposes.
However, the realities of regulatory control
are that a rigid set of requirements must lead
to a rigid conclusion about compliance.
Regulatory people are very uncomfortable
with fador-of-two accuracy.
Un fortunately. sometimes there are
missteps in ’he transitions between the steps
I have mentioned. Good basic research can
be followed bv bad .tpplied research. Good
applied research can lead into a bad practi
cal standard. A good practical standard can
result in a bad regulation. In this last case we
then have two kinds of hazard, a health
41
h izard a.id a regulatory hazai .l; and one
needs to be careful to specify which he
means. This is a most lamentable situation,
when! gening into compliance with the law
actually in*:eases (he health hazard. Fortunatelv. I on aware of only a few such ex
am, i. More of a problem is busy work requireiaero' diverting effort from mon! im
portant hazards.
Also common is the case where the standard
and the r»‘gu!ation are different but not
mutually exclusive. For example, there are
biological carcinogens and regulatory car
cinogens. and the lists are not the same.
/Another example is the frequent case in
which the regulation is of a “specification”
rather than a ' performance" type. Here it is
frequently possible to have a safe situation
but be out of compliance with the regulation.
The pom’ 1 am trying In make is that health
hazard and regulatory hazard should not be
confused in one’s thinking.
A general thought 1 would like to introduce
with re-.oecl Io the development of occupa
tional hazard standards is that it is immensel\ useful Io have* a "natural" source of
whatever agent is under consideration for
compaiison purposes For example, our sun
is .i familiar source of a wide range of non
ionizing radiation to which the human race
has become more or less accustomed. The
ability to relate quantitatively the various
"artificial" source's in the occupational en
viron iner.l is a great help in the development
of practical standards. It becomes a little
silly to agonize over an ultraviolet radiation
exposure standard that represents a small
fraction of the dose the person gels on his
way Io or from the parking lot.
1 would now like to discuss briefly some
practical issues imolving potential non
ionizing radiation hazards in the occupa
tional setting.
ARC WELDING
Among sovcral olhrr non-radiation welding
hazards such as the release of toxic chemi
cals. ozone production, and eardrum per
R \l»l \ ilt-S
‘oration, the significant non ionizing radia
tion hazards are those from infrared, visible,
and ultraviolet. The near infrared and visi
ble portions of the soectrum could constitute
a retinal burn ha
d if intensity were ade
quate. nut this is probably no* a real problem
lor ordinary welding. The retinal dose
seems to be less than that required to pro
duce injury, and the warning properties are
pretty good in that the welding arc is very
uncomfortable to look at.
The classic non-ionizing radiation hazard
from arc welding is that of "flashed eyes" or
ultraviolet keratoccnjunctivi’is. This painful
but temporary condition leaves a lasting im
pression on its victim, and it rarely happens
to him the jecond time. Few of you who
have been around industry for a while have
not seen flashed eyes. It is interesting to note
that the condition often occurs in a nearby
associated person instead of the welder. In
my Navy experience it was almost always
the “fire watch"—the man posted nearby to
observe any fires the welder might start. At
Kodak Park we can n'call five cases of
flashed eyes in the last 20 years or so. All
five were welder s helpers; none was the
welder himself. In the same period, we have
had no case of injury by infrard visible
light, or ionizing radiation.
RADIO FREQUENCY HEATERS
Radio frequency power has been found very
useful for its healing potential for which
their are many i idustrial applications such
as glue heaters, plastic sealers and welders,
and dryers. The potential effects of overex
posure include the direct biological hazard,
and indirect hazards such as the influence
on electronic cardiac pacemakers.
The applicable standard is American Na
tional Standards Institul’’ (ANSI)
C 95.1-1973, and the applicable regulation is
Occupational Safety and Health /Xdministration (OSH;;) 1910.97 or its state
equivalent. The standard covers ■: large fre
quency range, and was designed around the
most hazardous part of that range. Thus, for
many RF heaters in the lower frequencies,
thf* standard is overly restrictive
42
.4-
/
In makjng a practical evdluaiion of a poten
tial RE hazard. I have found that an ex
tremely useful first step is to determine the
frequency. If Inis is not ui one of the In
dustrial. Scientific, and Medical (ISM)
bands of approximately 13. 27. 40. 915. 2450.
5800 or 22.000 MFz. the problem disap
pears. This is because the amount of leakage
radiation permitted by the Federal Com
munications Commission because of com
munication interference is well below the
level that would be of concern from an oc
cupational health standpoint. If the frequen
cy is in one of the ISM bands, the situation
will need to be evaluated. The lower fre
quencies are randy likely to be a problem as
a direct hazard because of their poor and
diffuse absorption. For the higher frequen
cies. we have a good standard.
One RF heater that has appeared on the
scene lately in great numbers is the
microwave oven, which is used in industry
mainly to enable the employee to heat his
lunch efficiently. In the occupational setting,
the applicable standard is the same OSHA.
1910.97. which is an exposure standard.
Covering all microwave ovens in addition is
a Bureau of Radiological Health (BRH)
manufacturing regulation that is an emis
sion requirement. In essence, it requires a
maximum of lOW/m^ (t m\V/cm2) at the
lime of manufacture and 50 VV/m2
(5mVV/cm2) subsequently.
.
J
I
In Kodak in Rochester we now have some 70
microwave ovens. At the time the first oven
was purchased, we decided to monitor
radiation leakage from the ovens on a sixmonth interval basis. A few years ago. early
in this experience, we found an occasional
oven leaking more than it should, but cer
tainly not at a hazardous level. The leakage
could always be fixed by hinge, latch, or seal
maintenance Our more recent experience
has been that significant leakages are rarely
found, and we are thinking of decreasing the
frequen.y of measurement. There is no
regulation that specifically requires oven
monitoring.
I feel that even an annual frequency of
monitoring constitutes hyperscrutiny in■VI
I... . ..... L
sofi’r as the actual potential for hazard alone
is concerned. However, there art* othc r con
siderations here such as coniidei'ce eng* ndered in regulatory ageiiit ir*. anti
rt'assur.mt.e of users lh.it |uslil\ the pro
gram.
INCANDESCENT F ILAMENTS
Electrically heated wires in transparent en
velopes can represent non-ionizing radia
tion hazard in infrared, visible, and
ultraviolet wavelengths In addition to the
obvious case of whole body heating from
large incandescent lamp arravs. the question
of retinal hazard occasionahv has arisen. In
general, the bulb with fros*. d glass or some
other diffusing arrangement is noi u retinal
hazard. The bare tungsten filament mav be.
Ixiw wattage bulbs with thin filam nts are
probablv not a retinal hazard: but w- know
that high wattage bulbs, particularly those
with concent rated filaments such as pro
jection lamps, can be. We know this not only
from theoretical calculation, but there* have
been instance’s of retinal burns from such
buibs. Sometimes the question asked has
been whether an unfrosteel bulb operating al
less than nominal voltage represents a
hazaro. On separate occasions. 1 have had to
run out the calculation at sever.d different
temperatures, and would suggest that at tem
peratures above 2000 or 2100 kelvins a
retinal hazard shoe’ 4 1 • ron>idere<l At this
temperature, the radiant emittance »s of the
order of a recommended maximum (not an
injury threshold). Although not ieju.ious m
this range, such temperatures would cer
tainly be uncomfortable, in the situation
where these filaments mu .t be watched for
inspection or other purpose, a liber could be
placed o'*er the bulb, or the employee could
wear standard goggles that would remove
essentially all the infrared, and enough of
the visible to make the operation i.omlortabit Since the infrared lontributes r. ithme
Io the task, it might -<s well
removrii.
High temperature filament operatmr i.»mbined with an envelope transp i; :Tit '«»
ultraviolet such as the relativelv Free tidy
dev eloped quartz-halogen lamps emu poteti
bally injurious amount-, ot l’\ and havt
caused ‘sunburn'- and -aratchv wes The
control is easy if the problems is recognized.
Suitable glass or plastic windows with low
UV transmittance is all that is necessary.
GAS DISCHARGE LAMPS
Low pressure lamps are rarely a concern
from the retinal burn consideration,
although low pressure mercury vapor lamps
with a transmitting envelope can be an
ultraviolet hazard.
Blacklights.** those low pressure mercury
ire lamps with an envelope transmitting
only near ultraviolet, are not a significant
hazard. The most comforting and memora
ble reference material on this issue was an
article on Go-Go dancers appearing in the
American Industrial Hygiene Association
Journal in 1969.
LASERS
Plenty has already been said about laser
hazards, and little more needs to be offered
here. There have been standards for laser
hazard protection almost as long as there
have been lasers. Naturally, these have in
creased in complexity over the years as
more and more information has become
available and as more and more thought has
been given to the development of recom
mendations. The preeminent standard in
the field now is ANSI Standard Z-136.1. It is
a good standard. Verbatim it would be a bad
regulation because of its complexity and
detail. More than a smattering of optical
physics is required to understand it The
only Federal occupational laser standard ex
ists in the Part 1926 (OSHA construction)
regulations. It is good, but covers only the
construction occupations. 1 anticipate a Part
1910 (OSHA general industry) laser stan
dard that will be based on (but I hope not
identical with) ANSI Z-136.1. In the mean
time. there are operable state regulations in
some of the states S<.»me of the state codes
art* good and some are terrible. 1 fear that in
some cases the regulation represents an
overreaction to a new and mysterious
hazard and is long on busywork ami short
on practicality.
ELE 2TRONIC CARDIAC PACEMAKERS
My philosophy about these devices in the in
dustrial setting is approximately the follow
ing: If an employee is weaung an electronic
cardiac pacemaker, we in the larger indus
tries with medical programs will know it.
This is because we will find it out when he
is hired if he acquired it before that time. If
he acquired it after that time, we will know
about his reason for the absence when he
had it installed.
Therefore, we will be able to ascertain
whether the employee was counseled by his
cardiologist or cardiac surgeon with respect
to electromagnetic interference, and we will
be able to advise him about potential sources
in his work place environment. If he has not
been counseled by his private physician, we
can see that he is or do it out selves. In any
case, there are probably some areas, for ex
ample around some RF heaters, that this per
son should not go.
The issue of access by a non-employee is
somewhai more difficult. Such a person may
be a visitor, a salesman, an outside mainte
nance man. or perhaps a family member at
tending an open house. In these cases, it
may be necessary to post signs, ask the ques
tion. or make certain areas off-limits.
There have been occasional expressions of
concern over microwave ovens as potential
sources of electronic cardiac pacemaker in
terference. This sometimes takes the form of
suggestions that warning signs be placed on
the ovens. There actually was such a mili
tary regulation promulgated.
On this issue. I fully subscribe to the posi
tion taken by the Bureau of Radiological
health in 1971 (hat the < • aeralized use of
warning signs at microwave oven installa
tions would he impractical and unnecessary.
This position is based on:
1. Such signs would focus attention on a
single source and fail to warn about other
sources of interference such as electric tools,
household and industrial appliances, igni44
tion and lighting systems, radio, television,
and radar systems, that could not be-effec
tively delimited by signs.
2. The signs would label all microwave
ovens as hazardous regardless of the quality
of the oven. Microwave ovens have leaked
less and less as time goes on. probably
because of a combination of the BRH regula-
tion and improved manufacturing techni
ques that would have occurred anyway.
3. Electronic pacemakers are becoming less
and less sensitive to interference.
4. In the real environment. m»crowave
ovens have not been shown to be a serious
cause of electronic pacemaker interference.
\
radiation
45
MEDICAL RECORDKEEPING
AND SURVEILLANCE
i
Preceding page blank
-?7
This session on medical recordkeeping and
surveillance was selected for inclusion in
the scientific program of the AMA Congress
on Occupational Health because of the pro
found changes going on in each of these
areas and the potential of these changes to
affect the practice of occupational medicine
as well as the health of the worker.
INTRODUCTION
Marcus M. Key, M.D.
There is a tendency to think of medical
records as old. dusty, difficult to decipher,
and quite boring, at least in retrospect.
Medical records have been around for a long
lime—dating back to ancient Greek and
Roman times. Sporadic attempts have been
made to standardize medical records within
institutions and specialty groups, but even
so retrospective research based on clinical
notes is almost impossible because of gaps
and variations in recordings. One of the
justifications for the Weed system of the
Problem-Oriented Medical Record is the
sorry state of medical records, but this is
somewhat like one political party justifying
its election bid on the miserable job the
other political party has done. The problemoriented approach may be fine for teaching
and for care of the patient who presents an
acute problem requiring integration of care,
but I am not sure it has direct application to
occupational medicine. However, some of
the ideas from the Weed system should be
useful in medical surveillance. For example,
a Data Base in the front of the record would
be a logical place to list occupational ex
posures requiring monitoring: and medical
surveillance and worker education could be
covered in an Initial Plan.
Unfortunately, medical recordkeeping like
the practice of medicine is becoming too
defensive and legalistic and hence time-con
suming and costly. The proposed medical
requirements in the so-called mini-stan
dards now being produced by OSHA and
NIOSH may well become self-defeating
because of the reluctance of physicians to
comply. Excellent analyses of this potential
KECORDKEU'ISi. AM) SI Ri EILLANCt
4H
p.oble.n have been made by the two
panelists. Roy Joyner, and others, and you
will be hearing some of these details this
afternoon.
Other aspects of medical records are also
undergoing change, in particular their
ownership and the confidentiality of the in
formation contained therein. 1 am sure that
most of you are familiar with Dr. Irving
Tabershaw's recent suggestion that the
ownership of industrial medical records
should be vested in the worker. There is
much logic in support for this, but on the
other hand there is the threat of increased
litigation, such as that recently reviewed by
George Annas in the Journal of Occupational
Medicme. There are many practitioners in
this cour. ry who could be persuaded to do
medical surveillance of industrial workers,
but it is primarily a medical practice they are
interested in. not protracted or recurring
litigation. Here again the resulting complex
ity may bt. self-defeating, and ultimately the
health of the worker suffers if there are
fewer and fewer physicians interested in
this field.
These are some of the changes, actual and
potential, going on in the field of medical
recordkeeping, and when you hear Doctor
Steiner's presentation of how one large in
dustrial medical department deals with the
prob’em now. I think you will appreciate
how much more complex the problem may
become in the future. Doctor Steiner makes
a good point about fractionation of require
ments for medical examinations, that is.
based on separate standards for each sub
stance with the likelihood of examinations
and recordkeeping falling due at different
and inconvenient times. I hope there will he
time for discussion at the end regarding the
simplification and coordination of examina
tion:; so as not to overburden the woi ker and
the medical staff.
Medical surveillance in industry, the other
subject Io be covered in this session, will be
presented by a physician who has devoted
49
much energy to the study of this problem on
a theoretical and practical basis. We are
going to hear Doctor Dixon say that the term
‘medical surveillance' is much to be prefer
red to biologic monitoring, and I whole
heartedly agree with him. However. I should
point out that the term 'biologic monitoring'
originated with the industrial hygienists and
is indicative of their ability and intention of
carrying out certain "health monitoring"
procedures—limiting factors being coopera
tion of the worker and ability to collect
blood, urine, and breath samples.
If and when OSH A recognizes the impor
tance of biologic monitoring, access to
monitored data will no doubt be given to
OSH A hygienists. We need to recognize that
medical surveillance is much broader than
the biologic monitoring performed by in
dustrial hygienists, and the confidentiality
line must be clearly drawn if this should
come to pass.
I would like to touch on one other subject in
my introduction to medical records and sur
veillance and that is. the purpose of it all. I
think we would all agree that medical
recordke<*ping and surveillance are not ends
to themselves but part of a greater goal of
assessing the adequacy of (‘xpesun* control
and protecting the health of the worke.’. Un
fortunately. there is a tendency for require
ments to be fixed and unyielding once they
have been prescribed in enforcement
language. Fortunately. OSH A has permibed
alternalix e medical examinations for
preplacement and medical surveillance
under the vinyl chloride standard—and this
without the need for a formal variance. 1
would like Io see the same degree of flex
ibility carried forward in the mini-stan
dards. Thus, we have potential problems
with the trade-offs belwetm flexibility and
specificity. Doctor Dixon will make some
suggestions in this area which are (‘specially
useful for multiple exposures. OSH A would
do well Io use Doctor Dixon's proposal as a
model in writing OSH A medical require
ments.
rh.oriikekpim; ami si rveillam j:
Medical records in the occupational setting
have been and are a topic of discussion
whenever occupational physicians meet.
The reason is that the record contains not
only the usual medical information of who.
what. when, and where, plus treatment, but
also involves why and how. When an
employee has an occupational medical com
plaint and requires medical care, the
reasons why and how for the illness cr inj
ury are important.
MEDICAL RECORDKEEPING
S. D. Steiner, M.D.
Occupational medical records are not for the
sole use of medical department personne5..
Others in the business organization may
need portions of the information contained
on the medical record. For example, the
safety engineer will want to know how the
employee was injured and why the accident
occurred. If an employee suffers a hand in j
ury while operating a machine, it is impor
tant to know just how the employee’s hand
was injured and why it was in the particular
place at the time of injury. It is not enough ia
diagnose and treat the injury: it is important
to prevent future injuries. This is the sur
veillance part of the medical record.
For our discussion, medical recordkeeping
and surveillance will relate to two areas one
dealing with the use of medical treatment
records to identify safety and health
hazards, and the other dealing with physical
examination procedures to assure that
employee health is not being compromised
because of the work exposure. Because
medical surveillance and recordkeeping are
so much of each new proposed OSHA stan
dard. these aspects are discussed first.
Under the OSHA standards and proposed
standards, medical recordkeeping and sur
veillance are being used in a coordiru ted
fashion. The standards specify the type of
examination that must be done, the records
that must be kept, and the manner in which
the records must be maintained.
RtCORDKEEP/\G AND St'RVEILLASCE
so
Using the proposed Sulfur Dioxide Standard
as an example, the standard provides a sec
tion on medical surveillance which spells
out the medical responsibilities of the physi
cian. For example, it stipulates that any
employee exposed to sulfur dioxide above
the action level or ceiling level must have:
1.
2.
3.
4.
5.
6.
7.
8.
Opportunity for medical examina
tion.
The examination must be done by a
licensed physician, during normal
work hours and without cost to
employee.
The extent of the examination:
a. Work history and medical history
with particular emphasis on
respiratory symptoms.
b. Examination to include chest film,
pulmonary function tests, eye ex
amination. and skin examination.
Periodic examination on at least an
annual basis.
Opinion from physician as to
whether or not the employee is at in
creased risk from exposure to sulfur
dioxide and whether or not the ex
posure would aggravate any medical
condition.
An opinion as to limitations upon the
employee s exposure to sulfur diox
ide and upon the use of protective
equipment and respirators.
A statement that the employee has
been informed by the physician of
any medical conditions which re
quire further examination or tieatment.
A copy of the physician's written opi
nion shall be provided the affected
employee.
Under the recordkeeping section it is stipu
lated that the employer shall keep an accur
ate medical record for each employee sub
ject to medical surveillance. The record shall
include:
1.
Physician's writlen opinion.
2.
Any employee medical complaints
related to exposure to sulfur dioxide.
Any information provided the physi
cian by the employer, such as:
3.
51
a. Description of the employr’-’s
duties as they relate to exposure to
sulfur dioxide.
b. The results of any exposure
measurements, if available.
c. A description of any personal pro
tective equipment used.
d. Employee’s estimated exposure
level.
To date, three standards have been adopted,
some 40 have been proposed, and a total of
some 400 are contemplated Considering
that each person exposed to levels of ex
posure warranting examination must he ex
amined. the demand for physician time will
be enormous.
Another facet of the magnitude of the ex
amination program is that each standard re
quires certain specified examination pro
cedures. For example, sputum cytology may
be required for one type of exposure, an
urological examination for another, liver
function tests for yet another, and so forth.
Consider, also, that one employee may have
exposures to two or more materials and
several special tests may be required. A
physician doing these types of examinations
will need some form of chart to quickly
identify the total number of tests required.
Tables I A-C show the varying tests required
for only a few of the proposed standards.
Extend this list with 40-100-400 standards
and the physical requirements become
awesome. It will be necessary as standards
are established to set up such a chart. Only
in this way will the necessary examination
procedures be known.
One other item that must be taken into con
sideration in any medical surveillance pro
gram is the fact that employees at risk must
be examined at the prescribed periodic
times. As a general rule, examinations are
prescribed on an annual basis, it is impor
tant that the examinations be repeated with
in the twelve months, fourteen or fifteen
months are not good enough. One plant has
used a system shown below in which the
responsibilities of the medical department
and controls are stated.
kECORDKtEPING AND Sl'RV EILLANCE
(Fiist Floor
Banaalore .
fGO 001
1
I
TABLE I - A
EMPLOYE MEDICAL SURVEILLANCE
Oc.lobrr. 1975
1
I
I 1
8
L
J
i
*=
!
fl
X X
•= ~
£
1 =
E ~
:- 2-E <=
X
X
X
/X
X
Vinyl Chloride
A
X
( 11 Ketones
p
X
Lead
p
X
Noise
P
(2) Ketones
p
Worker Exposure
Asbestos
p
A
CarcinoKrns
‘Status: A = Adopted
P = proposed
r
X
11
X
X
X
X
X
X
X
X
v
X
X
X
X
X
X
X
X
X
X
I
X
X
X
I
•=
■h
<
=
I
X
I
'I A
£
X
X
X
I
u
I
<
x
■E
i
E
E
.5
I 1
X
X
r
7
<
i
X
X
X
X
X
X
X
X
X
X
X
X
X
!
X
X
X
X
X
2
5
7.
7
I
____
i
• •••
I
£-
"= >
•1
I
!
it
n
i
f
f f
I I
i
I
11
I
(
I
I
f
I
!
Status*
X
X
X
X
x
x
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Medic.<1 History
Occupational History
TT
”
termination/or complaint
X
Pn*placement Exam
X
X
Periodic Exam
Annual/Biennial
X
X
m
Physician
b
Certification
m
Audiomptric
Visio i Acuity
X
x
b—
EKC
(’.best X-ray
53
X
=
Pulmonary Performance*
>
8
LAB EXAMS X
I irinalysis
Snutum Cytology
Urine Cytology
X
X
Complete Blood Count
Blood Chemistries-
SCOT
SC PT
Alkaline* Phosphatase
'fol.il Bilirubin
CGTP
Lead
Olhers
53
KKCOl.'JKl.tPIM; AM) M KVFJ.! AM h
TABLE I - C
EMPLOYE MEDICAL SURVEILLANCE
I
I
1
!
I
I
E I
i 1 it 1 J I i
1
1
1
2
.2 3
.= c:
I
X
il t a
Worker Exposure
3
C.yclohex me
P
X
Camphor
P
X
Mesityl Oxide
P
X
X
X
S-Methyl-3 heplanone
P
X
X
X
Ozone
P
X
X
Toluene
P
X
X
Beryllium
P
X
X
z
X
7.
^r
I
X
<
I I II J
1 J
i
11 1
I
3
t
£
•r
'i
=
1
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
§5
5
7.
•Status. A = Adopted
P = Proposed
!
7
J
MEDICAL RESPONSIBILITIES
Medical schedules those requiring physi
cals
Physical completed
Safety audits monthly
r
Requirements:
Prepiacement — Within 30 days
Annual physical exams thereafter
Termination — Within 30 days unless ex' mined within the past l-year period
Supervision is responsible for sending to the
medical department each month the names
of exposed employees. Medical is responsi
ble for determining that the employee has
either been examined or. if not. an examina
tion is scheduled and physical examination
completed. The safety department must do
monthly audits to be sure that everyone has
done his job properly. The figures below
show how the audit sheets are used.
Controls:
Supervision supplies monthly record to
medical
Medical checks tiles
MONTHLY ASBESTOS AUDIT
Depaiime it Lists Received by Medical (Prior Month).
Ail Lists Received: Yes
No
Number of Lists Not Received
Department
Date Notified
Date List Submitted
1
2.
3. ...
4 _
Employees Scheduled for Physical Exam
Al* Employees Scheduled: Yes
NtTi’ber of Employees Not Scheduled
No
Name
Soc. Sec. No.
Date Scheduled
Soc. Sec. No.
Date Examined
1________
2________
3._____ _
4 ________
5 ________
Employees Given Physical Exam
AU Employees Scheduled: Yes
Number of Employees Not Examined
Name
1____
2. ___
3. __
4. ___
5. ___
6. ___
7. ___
8___
9.___
No
10
55
RE(:<)RtlkEEHM. AM) Sl kVEILLANCE
i
*
The medical department must make certain
that the employee lists from the departments
where exposures occur are received. Once
the employee lists are received, the medical
department must list all employees
scheduled for examination or the dale ex
amined.
Depending upon local situations and the
number of employees involved, some form
of accounting system for maintaining a
proper exam in at ion schedule is necessary.
The one described here is only one of •T»'»ny
that might be used. This may si cm like a lot
of bookkeeping and it is: but if employees
are to be protected, a system i.iust be
devised so that all exposed employees are
known to the medical department and it is
known that their medical examinations are
not only current, but that examinations
revealed nothing that prohibits the
employee from working in the area.
Another area of medical records and sur
veillance deals with the OSHA Log Form
100 and Summary report Form OSHA 102.
These two records contain the information
about all employes who become ill or in
jured as a resil’d of their work and also
record the -u-verity of th*' illness or injury.
Analysis of these records is very helpful in
discokering safety and health hazards in the
work en vironment, provided the records are
accurate.
Accuracy of these records, particularly
OSHA 100. is not easy to achieve. There is
difficulty in getting uniform recording of the
nonserious cases. Recording is required for
each occupational death and occupational
injury or illness "which involves one or
more of the following: loss of consciousness,
restriction of work motion, transfer Io
another job or medical treatment (other than
first aid)." Determining what cases are first
aid and which are not causes the difficulty.
Not infrequently, two plants with similar
work forces and health and safety exposures
will have wide differences in record-able
cases. The difference is due to improper
recording. Because the OSHA 100 identifies
areas where injury and illness occur and
reveals tne breakdown in the preventive
K. ..ORDhEl HSi; AM) SI RVHLLVNCE
health and safely programs, proper record
ing is necessary. Some guidelines have been
developed which have done much to obtain
more uniform reporting.
The guidelines are as follows:
Prescription Medication Use of prescrip
tion medication normally constitutes medi
cal treatment. The use of pain relieving
medication may be prescribed in single or
multiple doses without constituting a rc.'.or
dable case. Other medication when
prescribed for objective? findings will con
stitute a recordable case. Medication for pre
ventive purposes, such as tetanus toxoid,
does not in i.M?lf cause the case to be con
sidered medical treatment and recordable
Medical Treatment A case that norm.illy
inquires treatment by a physician is con
sidered medical treatment and recordable
even though the treatment was pro\ ided by
a registered professional other than a physi
cian. A case that normally would not require
treatment by a physician is considered fiisi
aid and should not be recorded even though
the first aid was provided by a physician.
First Aid Treatment One-time treatment
and subsequent observation and redressirv’
of minor cuts, burns, splinters, and so forib.
which would not normally require treat
ment by a physician.
Medical Treatment vs. First Aid The
following an? guidelines in'determining the
recordabili’y of various types of injuries:
Lacerations
First Aid Treatment is limited to clean
ing wound, soaking, applying antiseptii
and/or medication (see Prescription Medica
tion). bandaging, and/or the use of tape for
closure of superficial lacerations. Follow-up
visit is limited to observation, changing
dressing and bandage, and additional clean
ing and application of ^.antiseptic where re
quired by exposure to th, ( nvironment
Medical Treatment Injury requires
sutures (stitches), treatment of infection, or
other professional treatment.
Abrasions
First Aid Same as for lacerations, except
ointments may be added on follow-up visits
to prevent drying and cracking of skin.
Medical Treatment Injury requires
removal of embedded foreign material,
multiple soaking or whirlpool treatment Io
control infection or remove residual foreign
material, treatment of infection, or other
professional treatment.
Bruises
First Aid The bruise does not cause sig
nificant limitation of motion and does not
require treatment by a physician.
Medical Treatment Cases in which the
bruise causes significant limitation of mo
tion. extended care, or use of prescription
medication.
Splinter* and Puncture Wounds
First Aid Treatment 'imited to cleaning
wound, removal of foreign ./bject(s) by for
ceps or other simple techniques, application
of antiseptics and m.-dicalions (see Prescrip
tion Medication j. and bandaging on first
visit. In folb. w-up visits observation, chang
ing bandage, and additional cleaning and
application of antiseptic are considered first
aid where required by exposure to dirty en
vironment. Tetanus booster injections are
considered as a preventive treatment and do
not in themselves constitute medical treat
ment for recording purposes.
Medical Treatment Injury which would
normally require the attention of a physician
due to depth of embedment, size or shape of
object, or location of wound.
Burns. Thermal and Chemical
First Aid Treatment limited to cleaning
or flushing surface, soaking, applying cold
compresses, antiseptics and/or medications
(see Prescription Medication), and bandag
ing on first visit and follow-up visits for ob
servation. changing bandage, or additional
cleaning. Most first and second degree
burns are amenable to first-aid treatment.
Medical Treatment Injury requires a
series of treatments including soaks,
whirlpool, surgical (iebricb’ment. and ap
plication of medications Mos! third-degree
burns require medi' <i treatment. The
57
amount of body surface burned, the depth of
the burn, and the treatment rendered all
contribute toward determining whether or
not a case is recordable.
Sprains and Strains
First Aid Treatment is limited to soak
ing. heat treatment, microtherm, whirlpool,
medication given for pain, and use of elastic
bandage on first visit. Follow-up visits for
observation, possibly including reapplying
bandage.
Medical Treatment Injuries that signifi
cantly interfere with range of motion and re
quire series of hot and cold soaks, use of
whirlpools, diathermy treatment, or other
professional treatment.
Fractures
First Aid Treatment considen as first
aid when X-ray examination is made as a
precaution and results are negative.
Medical Treatment Incident where X
ray results are positive or other professional
treatment is administered.
I’ve Injuries
First Aid Treatment is considered as
first aid when of a moist swab in order to
remove adherent foreign body or material
which has not disturbed the epithelial sur
face or the eye. If medication is used, refer Io
Prescription Medication. Precautionary visit
»o a physician is still considered first aid if
treatment is limited Io above items. Follow
up visits for observations only.
Medical Treatment Removal of embed
ded foreign material or remaining rust ring,
treatment of any disturbance of the
epithelial surface, such as an abrasion,
would constitute cases involving medical
treatment. Also, a cast? requiring thi* use of
prescription medication (see above) or other
professional treauneni may be considered
medical treatment. Sever*1 welder’s flash re
quiring patching, local anesthetic, or treat
ment by a physician should be recorded
With the above guidelines, the OSHA Form
100 will list the meaningful injuries and ill
nesses. These an? the individuals who have
become ill or injuri'd al work. These cases
should be studied by the doctor, the safetx
KM.OKrikKKJ’IM; AM) SI R\ Hl.t. Wt )
!
lr
t
Ic
/
/
I
director, the industrial hygienist, and any
others who have to do with the plant safety.
Hazards can be identified and corrections
made. This does not mean that hazards
should not be identified and corrected
before injury occurs. Thai is implied. But
when an injury does occur, it should not be
limited to treating the ♦unployee. More important'y. steps need to be taken to avoid the
second case. Studying and using the OSHA
100 and 102 properly will accomplish this
end.
In conclusion, recordkeeping and sur
veillance are not routine endeavors. If they
become so. employees will not be properly
protected and the full value of the medical
department will not be realized, if regula
tions must be adhered to. then it is realistic
to get the most benefit from them as is possi
ble.
I
t
mi
»\dsi rv eh.lwce
58
Several years ago at an American Occupa
tional Medical Association meeting. I pre
sented a paper entitled "Medical Sur•ccillance in Industry.” At that time 1 thought
i knew most of the answers; now I am less
sure—but also I am certain that no one else
knows all the answers. However, having
long been concerned and having given con
siderable thought to this subject. 1 envision
my role on this program, at least in part, as
being somewhat the devil s advocate.
HEALTH SURVEILLANCE IN
INDUSTRY
Ernest M. Dixon, M.D.. Sc.D.
I think of health surveillance, especially
when we currently view it to be one of the
means of assisting in the protection of the
health of workers and in meeting com
pliance requirements of the Occupational
Safety and Health Act. as being awesomely
complex, limited in its capacity to ac
complish what is expected and logistically
difficult. In part this is due to extreme prob
lems with our entire system of national
health care delivery, and I find myself
deeply troubled and concerned with the
developments which 1 have seen of late.
Hence, it is my intent in this presentation to
share with you some thoughts that are
perhaps non-traditional and some differing
perspectives.
This being our Bicentennial Year. I wish to
recall two quotations appropriate to these
deliberations:
In 1782. six years after the Declaration of In
dependence. Jean de Crevecoeur stated:
“What then is the American, this new man?
He .s an American who leaving l^chind him all
his ancient prejudices and manners receives
new ones from the new mode of life he has
embraced, the new government he olx'ys. and
the new rank he holds. The American is a new
man. who acts upon new principles. He must,
therefore, entertain new ideas, and form new
opinions ...”
And in 1787. just five years later, that early
and eminent physician Benjamin Rush
recordkekhm; and si rv ejllance
59
wrote: "The American ivcir is over. But this is
far from Itt-inti the cost; with tin' Americun
Bi’x obition On the ('o/itrory. nothing but the
first act of lhe gnxit drumu is doused. It n?nuiins
yet to. (establish and jM'rf(?ct our new forms of
!»<*» ».rr.ment. and to prepare the principles,
nmniis and manners of our citizens for ihtfse
fornc-i of governmeni after they ure,t‘stublished
and b;ought to /x‘r|ection."
Wli.al !’m driving at is that much of our tradi
tional approach is of reduced relevance to
day: ’hat innovation and new methods are
di-sperately needed: and that the regulatory
process remains disturbingly imperfect. It
is. therefor.-, mv purpose to review some of
the problems and to allude to some possible
solutions.
An analysis of the objectives of health survedlance requires consideration of some of
the problems and inherent myths with
which we are faced. As each newly pro
posed standard for a given chemic.il ex
posure issues, it has its unique specifica
tions and language of health surveillance re
quirements for that substance alone. In the
idea' circumstance* such might be appropri
ate; but in the 'real world" sense, this is very
unsatisfactory and an imminent problem for
a variety of - reasons, prominent among
which are the following:
Multiple Exposures It is ran* for workers
to be potentially exposed Io a single sub
stance only. Although such may occur at a
given moment, over a period of lime (days,
weeks, or months), the probability of multi
ple exposures exists in most instances.
Perhaps 1! was otherwise in times past—but
cert.'inly not now. Hen* we encounter the
first stricture in the application of scientific
principle.- and methods; when we know that
health surveillance presetoiy is incapable in
all bill rare instances of measuring any im
pact in the one-cause/one-effect relationship
between an agent and reaction to it. how can
we expect to realistically assess the multi
ple-cause/perhaps-mo re-th an -one-effect
ccndidon? The application of Koch's postu
lates would be truly strained.
Multiple Effects of Individual Ex
posures There are many examples of varyRECORfiKEH'IM.
M RVrH.LASCE
ing effects from individual exposures to
hazardous agents just as there are varying
responses to naturally occurring diseases.
Variations of response include the catego
ries of acute versus chronic, localized versus
disseminated, the reactions in various organ
systems, and the impact in healthy versus
unhealthy, young versus old. male versus
female, and so forth. Good examples are the
great imitators, lues and tuberculosis, which
present greatly differing manifestations
under differing circumstances.
Interaction of Occupational and Nonoccupational Factors The range of
variability in human response is dramatic.
In determining the interaction of a poten
tially hazardous agent, one must consider all
of the variable characteristics of the in
dividual such as his respiratory rate. size,
metabolic pattern, genetic constitution, per
sonal habits, multiple factor etiology, and
other aspects of variability of response. In
other words, the real measure of hazard to
the individual is what is absorbed into his
system and the physiologic response which
this engenders. Inevitably this brings into
play a dose/effect relationship—a concept
which we must staunchly support and pro
mote in contrast to an empirical zero
tolerance outlook for which there is no
physiologic justification.
Complexity of Health Evaluation This is a
very real problem and is growing with the
passing of time. Simple tests and observa
tions of the past years have been supplanted
by vastly more complicated and technically
involved methods. The Report of the Na
tional Commission on State Workmen's
Compensation laws slates: "Technological
advances have produced unfamiliar and
often indeterminable physical and toxic
hazards. Occupational diseases associated
with prolonged exposures to unsuspected
agents or to fortuitous combinations of
stresses have undermined the usefulness of
the ’accident' concept. While advances in
medical knowledge have facilitated the treat
ment of many injuries and diseases, they
have also enlarged the list of diseases that
may be work-related. Simple cause/effect
concepts of the past have yieldt'd to an ap1.0
preciation of the many interacting forces
mcnt. Workers are people and most be treat
that may result in impairment or death. In
addition to genetic, environmental, cultural,
ed in the most humane way possihh*—not aS
and
influences,
psychological
physicians
subjects of a scientific study—and for this
reason, the term biologic monitoring' is -aot
must consider predisposing, precipitating,
aggravating, and perpetuating factors in dis
ease. Etiologic analysis, estimates of the
relationship to work, and evaluation of the
appropriate and too limiting.
extent of impairment have become accor
requirements under new standards. I cer
tainly agree to the importance of allowing
dingly complex for many illnesses."
Thus, it is readily evident that our medical
task is difficult. A basic predicament in oc
cupational medicine is a limited technologi
cal capability for health surveillance analyti
cal methods. When one considers tin* large
number of chemical substances in use. in
contrast to the few for which we have estab
lished and confirmed ability to assess ab
sorption and effect reliably, the magnitude
of the problem is readily apparent.
I am troubled by the (‘mergence of all kinds
of new' surveillance schemes and differing
judgment and not circumscribing initiative,
but lack of any uniformity will create a
nightmarish set of problems and utter chaos
in any effort to assess the value of sur
veillance. This is especially true where there
are multiple exposures with differing medi
cal requirements. In the latter, differing ex
posures occurring sequentially over a period
of time might require numerous separate ex
aminations as well as new tests relating to
each new exposure. Administration wi hir:
the industry or industries for whom the in
dividual worked would be extraordinarily
Several additional matters of great concern
are our actual practices and standards for
and inter-relationships between the follow
ing:
complex, cumbersome, and difficult to
achieve. The physician or physicians
charged with the surveillance responsibility
would find the task confusing, troublesome,
and difficult to coordinate: this is especially
true for private practitioners to whom the
Health Surveillance First. 1 would issue a
plea for universally adopting the term health
place of medical
bulk of the job would fall: indeed, we have
already encountered physicians who have
sur
long provided good services to industry
veillance. for all clinical and other measure
ments of human functions made on in
dustrial workers. Since preparing this pre
of its vagarious and capricious requisites, in
addition, numerous physicians have indi
surveillance,
in
sentation. I have had access to Doctor Key’s
introductory comments. His statement con
cerning the origin of the term '‘biologic
monitoring" has substantially influenced
my thinking. He said. "I should point out
refusing to undertake surveillance because
cated reluctance or unwillingness to attest
that a worker has or has not encountered ad
verse effects from exposures, may or inay
not be physically lit to undertake working
with specific agents, and may or may not be
that the terr, biologic monitoring' origi
nated with the industrial hygienists and is
indicative of their ability and intention of
physically able to use protective devict s. for
carryingout certain health monitoring' pro
cedures—limiting factors being cooperation
of the w’orker and ability to get blood, urine
For these and many other reasons, it has
long been apparent to me that the only
reasonable answer is the adoption of a
and breath samples."
uniform basic core health surveiil'.nce
scheme where surveillance is deemed es
sential. This would consist of a standardized
medical history, physical examination, and
The
primary
function
of
all
of
these
measurements is to keep a vigil on the health
example, respiratory equipment.
ciplinary approach designed to protect the
health of the workers and one designeil to be
clinical tests such as chest X-ray. pulmonary
function urinalysis, hematology, and blood
chemistry tests. To that would be added, as
positive—aimed
set forth in the standard issued for a given
of the workers. Il should be a multi-dis
bl
at
prevention, not
treat-
RHOKOkEti’INC AM> M KXFJM.AM.E
............... :...
a.
exposure, any unique or particular test or
tests, if any. that would be specifically
helpful or diagnostic for that substance.
Thus, there would be a basic procedure
common to all surveillance requirements—
with the addition of other observations only
when such is markedly indicated. The adop
tion of this plan would result in.
a.
b.
c.
d.
Simplification of surveillance for
all concerned with avoidance of
duplications and redundancies.
Greater ease in administration—
especially for physicians.
Improved quality of examinations
with attendant greater probability
of attaining the intended objec
tives.
Facilitating comparative study—
between different locations, com
panies. and so forth, and long-term
retrospective or other epide
miologic study.
Provision of the basis for long
term audit of the results and the
success or failure of surveillance to
help in worker protection.
With respect to the latter, failure of th»*
NIOSH-OSHA team to periodically audit
and determine the value of surveillance
plans would be a tragic mistake. I am aware
of no such plan at present and believe it
should be incorporated into the system vir
tually at its inception. Without it. necessary
changes or corrections and new approaches
will not be adopted.
1 am pleased, however, to announce that
such a core medical examination has been
proposed by the physicians sub committee
of the Occupational Safety and Health Ad
ministration standards group of the
Organization Resources Counselors Inc. It
has been presented to the National Advisory
Committee on Occupational Safety and
Health and has been favorably received. We
have learned that this scheme will probably
be adopted, at least on a trial basis to be
used when such examinations an* given to
employees of the Occupational Safety and
Health Administration of the U.S. Depart
ment of Labor. Th-s is a very encouraging
development.
MM.OKPKtM'IXC; AM) SI K\ Ell 1 .\\< r
I must point out that our intent was not to
encourage OSH A to require examinations
of .ill employed persons. Rather, it is an at
tempt te. standardize OSHA required exams
to facilitate compliance, bolter worker pro
tection. and to «i:.d physicians in doing a bel
ter job.
Industrial Hygiene Monitoring Implicit in
any ventun* io protect the health of workers
from potentially hazardous agents is a suita
ble and effective .qiprais.il of actual work
place exposure? levels. /\ll too often in the
past there has becm an inadetpiate history of
potential exposure and a lack of precise
analytical monitoring. Great strides in
developing precise analytical methods have
been madt* in recent years and this effort
needs to be pressed vigorously. It is obvious
that such data sh -uld be coordinated with
health surveillance systems: but too often
this is not done or not properly under
stood—especially .‘.nd understandably by
physicians unfamiliar with industrial con
cerns or toxicological principles
In this sphere of interest it is essential that
there be concern for the possible influence
of other unknowns such as coincidental ex
posures. contaminants in even trace
amounts, and variations in content that may
occur from lime to time.
In no way do 1 wish to imply or even suggest
that industrial hygiene analytical and related
functions are in any manner less important
than we have always considered them. They
are. in fad. the cornerstone and basic foun
dation of our planning io prevent ill effects
from toxic and other harmful effects in the
work environment In my judgment, purely
industrial hygiene measures have con
tributed mon* than have purely medical ac
tivities in reducing the effects of toxic sub
stances. radiation, and other forms of
energy, noise, heat and (.old stress, ex
cessive work effort, ami many other poten
tially harmful influences on our working
people. Nevertheless, the most diligently ap
plied industrial hygiene programs are in
herently beset w ith the possibility of failure
in that thev cannot possibly provide* absolute
assurance that the worker is safe. Even if
62
Threshold Limit Values are observed
scrupulously, there is no assurance that the
individual adheres to practices that preclude
excessive exposure. Breaks in techniques of
safe working practices, such as unplanned
skin exposure or handling contaminants
just prior to meal time or smoking can totally
invalidate the most exactingly carefid pre
cautionary plans. Newer methods utilizing
personal sampling monitors which con
tinuously measure the individual's actual
environmental exposure may help greatly,
but they do no! take into account transdermal absorption or any failure based upon
sudden brief exposures at high levels
beyond the capability of the instrument to
cope. If fail-safe, continuous persona!
monitoring equipment capable of handling
all levels of exposuie with reliability are
developed, then, except for dermal or ora!
exposure possibilities, health surveillance
might no longer be needed for routine in
dustrial health control. However, as
Stokinger has indicated, air-borne con
centrations as an index of exposure are also
unreliable in situations of mixed exposures
with metabolic interaction, individual
peculiarities of work habits leading to ab
normal intake, and additive exposure off the
job. By reflecting all of the possible varia
bles. health surveillance may become suffi
ciently advanced to provide both an index of
exposure and an index of response. Accord
ingly, only health surveillance techniques, if
available for the specific exposure, could
ascertain that the individual worker is com
pletely safe and has incurred no adverse
effects. Much research and development of
new methods is needed before that comfort
able condition obtains. In interim it must be
hoped that there is sufficient understanding
and wisdom to accept the unavoidable but
serious limitations with which we are now
shackled
Epidemiology The epidemiologic record
related io occupational health and illness
(and for (ha! matter, of natural disease, too)
traditionally has been appallingly inade
quate. Without a valid and usable base of
health surveillance and related worker ex
posure data, the best of epidemiologic
schemes will he of only crude quality. This
provides cogent emphasis as to the need and
63
importance of auditing and scientific assess
ment of the results of our surveillance pro
grams.
Disability and Workers’ Compensa
tion The quantification of disability and
determination of the degree attributable to
occupation truly defies or eludes us tecnnologically today. This precludes the other
perspectives of concern (moral, legal, and
economic) from being dealt with objectively
on a wholly fair and rational basis. Certainly
exacting and proper recognition of occupa
tional disease or adverse effects in the input
side of the equation is the weakest link in
the entire process. No magic answers are ap
parent in the immediate offing and there is a
great need for long-term follow-up of the
natural history of disability and its relation
ship to compensation practices. This partic
ular consideration may not seem related to
my topic—but this, plus our humane efforts,
becomes the “bottom line" when we fail.
All of these issues indicate? that there are
many unsolved matters and that our work is
clearly cut out for the future. It is obvious
that there is an abundant need and clear
urgency for major change and realignment
of priorities and policies for overall national
and occupational health care delivery
systems. In order to achieve a successful
capability for health surveillance of
workers, several special needs emerge:
1. Record systems are critical and much
needs to be done tn make them more
meaningful. Computerization is absolutely
essential for correlation with work environ
mental data, comparative studies, proper
and required record retention, and the audit
function. Compatibility between systems on
areas of primary concern is essential. This
in no way precludes individual organiza
tions from embellishing the scope to
whatever extent they desire.
2. Improved science is imp<‘rativr.
Despite the remarkable advances in analytic
capability, especially in the chemical area,
much more is needed and capability in the
biomedical sciences is far behind. This lag
has. in fact, aggravated our problems in that
AM) SI KVEItl-AM E
we can analyze for levels of exposure far
lower than we can determine what, if any.
physiologic effect has been induced.
3. In order to meet the work load increase
that will be necessitated by health sur
veillance requirements, persons other than
just physicians and nurses will have to
become trained and utilized. The adoption
of many screening procedures by techni
cians and other suitable paramedical per
sonnel will become a must. The total task
will require involvement of these in
dividuals plus the physicians, nurses, in
dustrial hygienists, toxicologists, and other
support personnel engaged in a cohesive
team approach.
Much more could be said, and I'm sure that
extensi.e argument could be generated, but
this has represented a gen<-ral airing of the
subject and some of the enigmas to be en
countered. From these thoughts perhaps
three hypotheses can be offered:
1. It is currently impossible to establish a
rational basis for assessing the impact of all
the combinations and permutations of ex
posure to many agents—single or multiple
with differing characteristics and propor
tions.
REl.ORDktt.PIMi .AM) SI R\fJLI.ASCE
2. The quantification of industrial hy
giene measurement and of medical ocservations both are extremely important—but a!
this stage in the development of the art they
can be highly deceptive and subject to grave
ly erroneous interpretation. We need beGer
science and deeper understanding, judg
ment. and wisdom before the numbers wi'l
provide all the answers.
3. The sum effect on health is the conse
quence of interaction among:
a. A genetically constituted and
uniquely constructed human being.
b. The influence of naturally occurring
diseases.
c. The impact of occupational ex
posures.
d. All other environmental and per
sonal endeavor influences.
Consistent with this state of affairs. I believe
our greatest efforts should be directed less to
the numbers game and more to establishing
principles and systems that may help ur. all
to accomplish our intended objective— pro
tecting people from incurring adverse health
effects resulting from their work. Finally, t
urge the adoption ami uniform usage of the
term health surveillance.
M
INTERDISCIPLINARY TEAMWORK IN
THE HEALTH/SAFETY PROFESSIONS
As the first speaker for the panel. I would
like to outline briefly a somewhat idealized
comprehensive occupational heal’h pro
gram. Il exists in concept, and. for the larger
part, in fact, at the Kodak Park Division of
the Eastman Kodak Company, a manufac
turing plant for sensitized photographic
goods and chemicals, employing approx
imately 32.000 persons. Some elements of
the health program are still under develop
ment or in prospect. 1 do not have direct ex
perience with safety activities. However,
safety is represented on the panel by an emi
nent safety professional. David MacCollum.
who will speak from his very rich ex
perience about that important program area.
THE ROLE OF
THE MEDICAL
PROFESSION
William D. Hoskin, M.D.
There are four aspects Io the occupational
health program. They include clinical
medicine, environmental health, health
maintenance, and rehabilitation. In the clini
cal area, of first importance is the capability
for emergency medical response. A plant
wide first-aid strategy is currently being
reorganized under ihe direction and coor
dination of the Medical Department. /Xn inplant ambulance is crewed by a nurse or
physician but maintained and operated by
the Fire Department. A dispensary is open
and staffed by health professionals 24 hours
a day. It is (’quipped to provide emergency
treatment for most medical emergencies incfuding acute coronary occlusion.
Casual ambulatory patient services repre
sent a major activity. Any company person
may be seen in the Medical Department for
illness or injury or for medical advice or
evaluation. The service is intended to res
pond to Ihe immediate medical needs of in
dividuals at work. It permits early recogni
tion of work-related illness, and provides
prompt medical intelligence about illnesses
currently present in the work force.
Where indicated, diagnostic studies are per
formed sufficient to establish a working
diagnosis and plan of advice or management
H t\ I. THISA f KTY T EA M ll ORK
GG
for the patierH's problem. The plan m«v in
ing that many interrelated factors are in
clude work recommendations or woik
volved in the causation of disease—all are
prescription (we hope to be able to minimize
use of the term "job restrictions" with all its
contributing to a new dimension of illness
negative implications). If the clinical prob
lem is causally related to work, a specific
prevention and health maintenance. They
make it possible to better characterize the
health of individuals and groups in terms of
plan of management may be initiated. On
the other hand, if the illness or injury is not
is our ability to influence the long term state
so related, only interim treatment is offered
and referral is made for further manage
of health of individuals, particularly in
terms of deferring premature death or. even
ment by the private physician or other com
munity health resources.
more importantly, improving the quality of
individual lives.
A not inconsiderable effort is devoted to the
clinical follow-up of persons with chronic
health maintenance programs and activities
illness or disability. At appropriate intervals
the status of the patient's health is reviewed
are necessary to apply medical insights to
the prevention of chronic illness and also Io
and consideration given to any changes in
the patient's functional capacity or in re
expand these insights. The basis for the
health maintenance program is an extensive
quirements of the job.
system of health appraisals performed for a
number of different reasons which can be
The next major area of the occupational
health program is that of environmental
grouped under four headings. One heading
health. This is. in fad. the public health por
tion of the program. In the special com
munity and environment of industry, dis
ease-producing agents are seldom bacteria,
spirochetes, or parasites: rather they are in
those familiar categories of noise, chemicals,
radiation, heat, mechanical stress, and emo
tional stress. Environmental health objec
tives are. of course, to recognize. Io identify,
to evaluate, and to make recommendations
regarding the suspect hazards. Methods for
dealing with such a hazard are. in order of
preference, to eliminate the hazard, to
both pathology and function. Less advanced
In light of the above, it is our belief ’hat
is that of functional evaluations performed
for the purpose of determining functional
capabilities and functional impairments
along with clinical evidence of illness or
pathology. The occasion« for these may be
selective placement or licensure for special
duties such as respirator use or vehicle
operation.
Another very important classification is that
of occupational hazard surveillance wh>ch
includes those appraisals or examinations ■ jf
persons potentially or actually exposed to
environmental or occupational hazards. The
substitute for it. to control it. or to protect the
purpose of the evaluation is to discern the
exposed individual. T ie monitoring and the
earliest biological evidence of significant ex
investigation of the great variety of potential
industrial hazards is a complex and techni
cal matter, requiring the contribution of a
posure to the hazardous agent. Evidence
could range from simply the presence of the
number of disciplines in many cases.
agent in the body through early reversible
physiologic change to overt disease. Such
The term preventive medicine implies noble
surveillance calls for a comprehensive list of
hazardous agents, arranged in a matrix form
objectives. However, when one attempts to
with appropriate examinations designed in
translate the term into substantive programs
or techniques, the body of practice and tech
nology appears to be limited except in the
elicit the necessary medical information.
classical areas of immunization and public
health. New methods for observation and
measurement of biological structures and
functions, new applications of information
praisal is the routine periodic medical ex
amination. Purposes of these examinations
include early disease detection, comprehen
processing, and an increasing understand
67
A third and familiar category of health ap
sive risk profiling, and the establishment of
vertical (individual) and horizontal (group)
It L’.A i.TI IIS A FETA TEA M W ORE
iit
health baselines. They should be scheduled
for the. entire work force at those intervals
which are possible of accomplishment and
which serve the defined purposes of the pro
gram.
Fourthly, a health appraisal system can also
make it possible to study efficiently the
health of a group of employees with some
common identity, such as a department, an
industrial operation, a vocational specialty,
or a common work environment. Such a
cross-sectional study can serve
epidemiologic as well as personal health
A special area of rehabilitation has to do
with the counselling of the so-called
"troubled person." Changes in work perfor
mance and attendance, development of
uncharacteristic accident proneness, and
changes in attitude or behavior are identify
ing characteristics of a troubled person.
Depicting the reality of the declining job per
formance to such a person, as the initial part
of a coordinated but voluntary rehabilitation
plan, can be effective in helping such pa
tients deal constructively with the "trouble."
whether it be alcoholism, excessive unwar
ranted illness absence, or some other situa
tional. behavioral, or health problem.
purposes.
Information developed in health appraisals
can be applied in the form of advice or plan
ning which will enhance the health of the in
dividual or the group. The individual may he
provided counselling and appropriate refer
ral regarding disease discovered in the ap
praisal, or advice about measures to improve
a high risk factor profile. Recommendations
to supervision regarding safe work prac
tices. improved job methods, or hazard con
trols may also be indicated when unex
pected evidence of hazard exposure is
revealed.
Where illness or disability exist, the ultimate
objective of treatment and rehabilitation is
to restore the individual to a maximum level
of function. To participate and contribute in
an effective, productive manner in a signifi
cant job may be the optimum rehabilitation
end point. Historically, our role in the
rehabilitation process has been a relatively
passive one. Rehabilitation plans have been
carried out for the most part outside the
work place and without significant partici
pation of the Medical Department. It is our
belief that to preserve function and to pre
vent psychological and spiritual deteriora
tion. a more active rehabilitation effort on
the part of the Medical Department is
necessa/y. An early, active, and specific
rehabilitation plan should be formulated
and carried out. The Medical Department
should assist in the devising of support pro
grams for those individuals incapable of
continuing work on a long-term basis
HEALTH/S.4FET> TEAMM ORE
A number of resources and aciivities are
necessary to support the occupational hea'th
program which we have briefly describe.*.
Among them are the usual ones such as
diagnostic radiology, a clinical laboratory
service, a medical record system, and ad
ministrative services. However, some of
them are newer and less familiar.
The professional nurse, in the extended role
which is evolving, has been able to make i. ■
portant new contributions to the program.
With increased training and under medical
supervision, the nurse has been able to carry
out health appraisals, clinical evaluations,
and problem solving to a degree which has
not traditionally been possible. The nurse
has become involved in environmental
health activities and is expected to have ?
key role in the rehabilitation program.
The handling of occupational health infor
mation of many kinds has been enhanced,
and in fact made possible to a large extent,
by data processing technology. The storage
and retrieval of clinical information and its
selective confidential use for administrative
end epidemiologic and other purposes de
pends heavily on computer services. The
preparation of reports required by govern
ment regulation can be facilitated by these
information systems. The identification and
scheduling of individuals for health ap
praisals are heavily dependent on this kind
of resource.
Tn addition to the special scheduling needs.
the health appraisal system will need other
condition* will add much to our understand
kinds ci resources and support. For efficient
ing of th • p:.>t)lems. Large industrial
organizations with substantial occupational
operation, a facility must he designed to ac
commodate the volume and flow of subjects
anticipated. Job descriptions should be
devised for the professional, paraprofes
sional. and nonprofessional persons who
health programs will heed to consider the
creation of occupational health science
laboratories within their own organization.
Most small industri*?s. however, will proba
will staff the program. The availability of
bly not have use for full-time laboratory
physicians and nurses to give follow-up at
assistance but can arrange to have this con
tention tn the medical information generated
sultation available.
by the system is a crucial and limiting re
quirement. For purposes of review' and
analysis, it is useful to have a summary of
No program can succeed without the strong
medical findings stored and recoverable in
computerized form.
moral and material support of management
at all levels in the organization. Managers
must be aware of their health respon
sibilities. There must be a clear understand
As the needs and opportunities for occupa
tional health services change and expand, it
becomes necessary to provide information,
interpretation, and training about occupa
tional health matters to all of the individuals
and organizations concerned. Professional
staff require ongoing training in the techni
cal aspects of occupational health. Managers
and supervisors must be advised regarding
occupational health standards and practices
and the capability of the health services to
support them in those management respon
sibilities. Most importantly, individual
opeiators must be informed of any health
hazards i.i the work place or in the job
operation to which they may be exposed,
ing of goals and objectives. There must be
frm management commitment to those ob
jectives. Support in the form of facilities,
staff, and funds is needed.
The purpose for and the ultimate objective
of occupational health programs is to pre
vent illness and injury to the individual
worker. In addition to the programs and
resources described, there must-be a high
degree of personnel confidence in the health
organization, the program, and the profes
sional staff. Staff members must have pro
fessional credibility based on demonstrated
competence and genuine concern for in
and they should be instructed in safe prac
dividual needs. The doctor or nurse must
assume the role of. and be perceived as. the
tices to prevent such exposure. Training
efforts to satisfy all these purposes will vary
personal advocate in health matters. It
should also be clearly evident that the doc-
in content and in manner of presentation.
They will require intentional planning and
tor/patient relationship is a confidential one
competent training resources.
and that medical department procedures
will assure that information obtained in the
relationship will be secure.
Success of an occupational health program
depends very much upon the availability of
The comprehensive occupational health pro
occupational health science services. Impor
tant disciplines include toxicology,
gram described represents the current state
of the art as we see it. It also reflects new ap
plications of other disciplines and tech
biochemistry, industrial hygiene, human
factors, radiation physics, and bacteriology.
Of increasing importance is the science of
epidemiology. There is a notable lack of in
formation and understanding about most of
the potential health hazards in the work en
vironment. Experimental evidence is clos
ing some of the knowledge gap. but direct
observations of human health experience in
large groups with known environmental
nologies to that art. These programs are
becoming more diverse, more complex, and
more technical. It has become correspond
ingly more difficult for individual practi
tioners or professions to deal effectively
with all of the ramifications of occupational
health. The result is increasing compart
mentalization and specialization among the
occupational health disciplines.
HKALTH/SAFETY TEAMWORK
(Ml
J
These factors and a number of others com
bine to make it implicit that many occupa
tional health problems should be dealt with
by interdisciplinary teams. Industrial tech
nology continues to change in the direction
of increasing complexity and unfamiliar
hazard. At the same time the ability Io evalu
ate toxicologic, biochemical, metabolic,
pathologic, and other biological effects of
hazardous environmental agents is increas
ing and improving. Specialization is occur
ring in a number of professions in response
to the need. These include medicine, nurs
ing. industrial hygiene, human factors, tox
icology. health physics, and others. C.overnment regulations are requiring a higher
degree of commitment and performance
from industry, generally, in the area of oc
cupational health. Supervisors are being
assigned new and sometimes unfamiliar
responsibilities for the health and well
being of the persons in the work force. New
organizational styles call for participation in
the setting of goals and design of processes
by those whom the practices are designed to
help.
The team process provides a variety of view
points. a ferment of ideas, a special interest
in the resulting plan, and a sense of respon
sibility by the participants in making the
plan succeed. On the other hand, the ex
change and consideration of ideas is a time
consuming and laborious process. However,
used well, the team process can be creative
and can often contribute special wisdom to a
complex problem.
In response to these many factors, teams can
be useful for a number of purposes in the
occupational health program. The basic
health team may consist of the occupational
physician, the most broadly, extensively
trained member of the team and presumed
team leader: the (.ecu pat ion al health nurse,
whose extended role will be described in
greater detail later: and the secretary, who
may be able to assume other coordinating
and administrative responsibilities for the
team than the usual secretarial role. This
HEALTH/SAFET^ 7EAMMORK
team should have the basic responsibility for
carrying out the broad occupational health
program we have been discussing.
To deal with environmental health ques
tions. the area p» ysician is considered the
general practitioner of occupational health
but will often wish to convene a team con
sisting of a representative of the operating
division, an industrial hygienist, a human
factors specialist, the safety engineer, and
other technical specialties as needed.
A health appraisal center may be staffed Ly
nurses in the extended role, technicians,
clerical persons with limited clinical train
ing. and an administrator to coordinate the
activities of the team. A physician, of course,
is needed to oversee the program.
Significan.i improvement in rehabilitaf.on
practices will probably also depend to a
great extent on the ability to organize the
efforts of several professionals for the p'-r
pose. Once more the occupational physician
will need Io give direction to the team, but
special contributions can be made by the oc
cupational nurse, by visiting nurses with
rehabilitation training, by a medical
rehabilitation consultant, and by the attend
ing private physician. Not to be overlooked,
and crucial to the rehabilitation plan, is thi
patient's supervisor. Finally, the patient
should be included in the rehabilitation
planning.
In summary then, under the influence of
many social, political, economic, and tech
nologic forces, occupational health pro
grams are becoming more complex, more
diverse, more technical, and more extensive
than we have been accustomed to in the
past. An example of such a comprehensive
program has been described in this papep
The need for greater specialization in the
practice of occupational health has been sug
gested. along with factors which have in
fluenced that need. Some examples of inter
disciplinary teams have been presented
70
J
Our nation’s safetv and health problems
cannot and will not be solved until all profes
sions work together towards a higher degree
of care. This teamwork must extend far
beyond those who are professionally iden
tified with either the safety or health fields.
u:l us identify some specific professional
boundaries, so we can see who needs to be
on the health and safety team.
THE SAFETY ENGINEER’S
VIEWPOINT
David V. M.icColium, RE.. C.S.R
Bein^ an engineer. I see the professional
boundaries relating to safety and health as a
triangular pyramid—a three-dimensional
solid contained by four plane faces in which
each side directly interfaces with the other
three sides. The four disciplines which form
the faces of this health and safety
tetrahedron are economics, law. medicine,
and engineering. These basic relationships
cannot be dealt with individually, as this
would create an imbalance of the others. At
first glance, this perspective may be ques
tioned by many, but as we begin to examine
the tetrahedron. I think you will see the c’ose
interrelationship of these disciplines.
First, let’s take the one which appears to be
most out of place and establish it as the base.
This is "economics." We have never really
addressed the cost of human destruction as a
icsult of health and safety hazards. The cost
of injury, death, or impairment of health is
many times not borne by the party creating
the danger. There are countless people on
the t-^x rolls who have been disabled,
widowed, or impoverished because of acci
dents and are a tax burden because health
and safety were construed as unimportant
considerations. The true cost of industrially
induced health hazards and accidents is
ultimately reflected in welfare benefits to
the victims. Had the cos! of prevention been
included in the initial price of the machine,
product, facility, or service, the far larger
cost arising because of these accidents or
health hazards would have been eliminated.
Such waste is inexcusable. Today we know
that carcinogens are delayed time bombs.
71
HEALTHiSAl ETY TEAMHORK
J
The health care relating to these carcinogens
is largely picked up by health insurance,
public health, or welfare programs. Thus the
staggering cost of health care for black lung,
asbestosis, and the like has been reverting to
the public sector.
Years ago enterprise sought to stablize the
cost of traumatic injury (such as loss of
eyesight or limbs) or death as a result of
physical harm in the workplace by relying
upon workers' compensation to cover
losses. Workers' compensation has provided
incentives for the employer to provide a safe
work environment, but the employer who
h.is no intention of implementing a safely
program only runs the risk of policy can
cellation in the event of a large loss. This in
flates the entire rate-making structure to the
detriment of the good performer. In recent
years casualty insurance has come under
some measure of criticism for its inability Io
preselect the good risk from the bad. since
good management still fools the bill with
higher premiums to cover the losses ot lh(‘
poor performer
!
♦
Another facet of economics that often goes
unnotired as long as the employer pays the
bill through workers' compensation is the
responsibility of manufacturers to design
saf« machinery Machinery is often defec
tive and unsafe Because the inherent
dangers are often not readily anticipated by
those who use the equipment, many injuries
result. Tin* burden of safety should not be
upon the employee to do it right all the time,
every time’. These machines should be
designed by manufacturers so that the
operator won't sulfur grievous injury if a
misjudgment is made. Punch presst’s are
good (’xamples of machines that entrap the
unwary if thev happen to make an inadver
tent movement. I consider punch presses to
he "automated amputators." and they should
he better designed by manufacturers.
Once the cost of prevention is recognized as
infinitesimal when compared to the high
price of restoration, disability, or dependent
welfare, then economics will promol** in
centives for the obviously needed remedial
measures to prevent injury in the first place.
HFM.IMSAHin TEAMWORK
In summary. I contend that the lack of eco
nomic analysis has been the major underly
ing reason for neglect of emphasis on pre
ventive health and safety measures.
The next interlocking face of the
tetrahedron is the profession of law. By
pursuing the theory of tort liability, adver
sary concepts have focused upon economic
inequities. When the pocketbook is hit by
lawsuits arising from injury, impaired
health, or death, the economics of preven
tion become clear. These court actions have
fostered a concern for safety and health and
have provided the stimulus for many laws
on safety and health.
In many ways, the legal profession has been
the catalyst which has forced the issue of
health and safety Io become a national
priority. In the past, as long as the injured
had no way to present a claim, no cost*, were
incurred, and there was no economic incen
tive to improve safety and health conditions.
Now. when injury, death, or health impair
ment can result in financial restiaiticn. pre
vention takes on a new look and is con
sidered "good business" and the sensible
and essential way to go.
Let s turn to medicine. To me. this is the
sunny side of the tetrahedron Through
pathology, medicine has perceived many
silent killers, ameliorated the damage, and
prescribed the cure to eliminate the danger.
The research which has been done by the
medical profession is outstanding -n cor
relating some of the diseases of man with in dustrial contaminants. The engineer applies
his talents to devise control methods for
reducing the level of contaminants, flv* tox
icologists in their research have been able to
recommend the limits of exposure that the
human body can tolerate without irreversi
ble damage. In the area of human factors
analysis, we have been able to determine the
limits of physical and mental stress.
The fourth side of the tetrahedron is
engineering, more specifically safety
engineering which applies physics, chemis
try. and biology^ towards the ct^ntn-l of
physical hazards. It is my opinion that the
72
importance of sound engineering practice
will become absolute in the future. We have
reached the limit for reliance solely upon
human behavioral patterns. It is now recog
nized that inadvertent errors should not
result in catastrophic disability or damage.
The? solution lies in fail-safe? design and
development of safer products, and these?
options are m the* province of engineering. It
can be expected that design improvement to
industrial machinery will become a
necessity, since perfect human performance
is understandably unachievable. This con
cept is not new Some very sound com
ments. showing keen perspective were
made sixty years ago by prominent safety
engineers:
"If you want your plant to be 100 per cert
safe, the answer to the first question is—
guard every moving part, wherever located,
an which a workman might be injured if he
came in contact with it in any way or from
any cause whatsoever. If the moving part is
in a place ‘where nobody ever goes.’ remem
ber that someone is likely to go there sooner
o»* later, in connection with the repair or
maintenance or alteration of the machinery
itself or of the building, or for some other
reason which you cannot anticipate."!
"Along I he line of getting men to do things I
might spill a few beans.' I happened to be
one of the Committee on Safety and Sanita
tion of the National Manufacturers' Associ
ation. At our last meeting we adopted a
resolution that all manufacturers be asked to
alter the design of their machines to incor
porate safety to the full advantage of the fac
tory to their produc t. We also went on record
that we would advocate legislative action by
the House of Representatives to compel ev
ery manufacturer in this country to send out
his machines with all guards attached; no
open gears: all movable parts enclosed,
wherever possible; leaving c»nly an opening
sufficient Io get the belt on.
"Wr have not heard from them yet. but I can
assure* you that we wrote to each Represen
tative. I rece'ived a letter from our Rt presentative. statmv that he was heartily in favor of
it. that it was a fine thing, and that he would
do al) in his power to pass such a law. So.
gentlemen, you can see the trend is towards
making everything as safe as possible, and
when we get the House of Representatives
interested in th * matt’T. I think we an? on
the? road to success ">
With all e>f our aerospace technology, we? still
have not come te> grips with the basics. To
enjoy absolutes, we? cannot afford the? luxury
of allowing "half" a machine? to be intrexluceel inte> commerce* without safeguards.
Fancy laws, eserteric management programs,
motivational training, and sexy posters are
neu going Io assure* human reliability. In the
final analysis, it is the* engineer with an un
derstanding of safety who will provide?
design which takes the sting out of the varia
bles of human behavior and makes the*
machine? fail-safe.
The safety engineer will play an in
creasingly important role in the future
because he has the special knowledge that
will eliminate dangers that are not accepta
ble risks. The safety engineer can foresee
and predict where accidents will occur:
more importantly, it is he who applies
available technology for design so accidents
won't occur.
If the answers to our safety and health prob
lems are so close at hand, why are we so far
from success? The answer is as basic as the
question: we fail to examine total economics
and are inclined to consider safety and
healih in terms of initial expense rather than
measuring the cost of safeguards against
losses which can be incurred by their omis
sion. Our present incentives are directed
toward "chancing it." and we tend to risk
large stakes for very small economies.
A lew fresh trails have been broken in the*
direction of giving safety and health a first
priority. The most notable example* has been
to place* men on the* moon with assurance of
‘heir safe* return. This effort was accomplishe’d by using a syste ms approae.h in
which all discipline’s were channeled into
the safety anel health effort Every conceiva
ble? human error was considere*d. as well .is
Hf M.lHSXH.’n 7E.AMI1OKK
. ........
..
:,
...........
every possible mechanical or electrical malrancticn: effective controls were included as
fail-safe options. The result afforded nearly
absolute safety.
The space program showed that when
money is made available for safety and
health, hazards can be controlled. We are
also finding out in our free economy that the
cost of incorporating safety and health in
design is far less expensive than the losses
we are experiencing when these items are
overlooked.
From a safety engineering standpoint. 1
want to reiterate how important it is for the
engineer to have Ihe help of the pathologist
who identifies the offending carcinogens or
bacteria The skills of the psychologist, who
understands human behavior and why peo
ple err. are essential so the engineer can go
bark tn the drawing board and design a safer
world. We must work closely together. The
old saying that engineers plant ivy to cover
the cracks and physicians bury their
mistakes will not cut it in today’s world. Our
fellow professionals on the other sides of the
tetrahedron will get to us and focus on our
shortcomings. Pure economics will force us
to get with it or go broke.
All professions must become cohesive if a
safer and more healthful world is to be
achieved. Traditionally, it has been the role
of ihe professions to provide the expertise
upon which progress is made. When
progress does not meet public goals, it is not
usually the fault of the professions, but an
inability of the establishment, either in
dividually or collectively, to accept, adopt,
and support Ihe prescriptive measures
defined By the profession.
HE Al. 1H/SAFETY TEA MW (>Rk
I feel the time has come for the professions,
which have given us the high quality of life
we now enjoy, to hold the establishment ac
countable for safety and health. Nearly
seventy-five years ago President Theodore
Roosevelt said: “As modern civilization is
constantly creating artificial dangers to life,
limb, and health, it is imperative upon us to
provide new safeguards against the perils.”
We in the professions should express our
impatient dissatisfaction, in unison, in view
of these facts:
1.
2.
3.
4.
More than 105.000 men, women
and children are killed each year
by accident.
More than 11.000.000 per year are
accidentally disabled.
Actual economic losses approach
hundreds of billions of dollars
each year.
Unknown numbers of workers are
being exposed to harmful car
cinogens and other disabling ele
ments and are added to our
already staggering tax burden
through welfare and health care
programs with no penalty imposed
upon those who do not eliminate
the cause of such disablement.
Interdisciplinary teamwork among all pro
fessions is the "base” upon which to build a
safer world.
REFERENCES
1. Williams S | National Safety (Council Bth Safety
Congress Transactions. 1919
2. Williams W E. Packard Motor Car Company. Na
tional Safety Council Wh Safely Congress Transactions.
1917
74
Occupational health nursing has beer,
defined by the American Association of In
dustrial Nurses. Inc. as "the application of
nursing principles in conserving the health
of workers in all occupations. It involves
prevention, recognition, and treatment of ill
ness and injuries, and requires special skills
and knowledge in the fields of health educa
tion and counseling, environmental health,
and rehabilitation.’'’*
THE ROLE OF
THE NURSE
Bcirbora Healy, R.N.
Today's increased demands on the occupa
tional health services has brought about a
need for more complete utilization of the
knowledge and skill of the occupational
health nurse. The expanded role of the
nurse began at Kodak with the recognition
that nurses were interested in and eager to
accept the challenge of new responsibilities
and to increase their knowledge and skills, it
was further recognized that nurses repre
sent a vast—but partially untapped—poten
tial of health care providers. It was hy
pothesized that the professional potential of
our nurses could be utilized better by pro
viding appropriate education programs and
a proper setting in which to practice.
The Medical Department has been explor
ing ways to expand nursing responsibilities
To implement this action, a physician-nurse
committee was appointed. One of its deci
sions was io enter a nurse in the University
of Rochester School of Medicine's course for
nurse practitioners. This course taught th(.
techniques of the physical examination. Lir.
Barbara Bates and her colleague. Joan
Lynaugh. R N who jointly developed this
course, suggested that one of our physician:;
participate as an instructor. This was done
and provided the foundation for a course
conducted on a continuing basis by one of
our physicians on Kodak Park premises.
The course for nurse practitioners at Kodak
now consists of: 30 hours of training in the
techniques of the physical examination: B
hours in interviewing and history taking. In
addition, approximately 15 hours pur year
75
, ..
HEAI.rH/SAKElA TEAMWORX
...._________ ..L.._
.re spent in continuing education programs
on clinical syndromes and disease states.
Over forty nurses have completed this pro
gram.
7.
B.
I
To adequately see the setting in which
nurses apply this specialized training in
their role, you must visualize Kodak Park.
Kodak Park is a large manufacturing com
plex where approximately 32.000 people are
employed in the production of photographic
goods and materials. Because of the mag
nitude and complexity of operations, it is
impractical to expect any one physician to
be intimately knowledgeable of all the many
processes, health hazards, equipment, and
men and women involved. Recognizing this,
the Medical Department established an
“area physician' concept. An area is a
grouping of departments which, insofar as
possible, have similar functions. For exam
ple, the Research Laboratory complex is one
area. Photo Paper Manufacturing is another,
and so on. This enables the physician to
periodice’ly visit the area and to become
familiar with the operations and personnel.
Applying the Interdisciplinary Team ap
proach. it was decided for a pilot program
that an area could be served best by adding a
secretary on a full-time basis and a nurse
practitioner on an H-hour per week basis.
Since then other areas have been organized
on a similar basis, and in some instances the
nurse practitioner hours have been ex
panded. After five veats of experience wi’h
this concept, we feel that to obtain team effi
ciency. members of these teams need to:
1.
2
3.
4
5.
6.
Be familiar with the established
goals of the Medical Department.
Participate in the development of
learn goals and of an operating
style which wdl effectively ac
complish these goals.
Be familiar with the environment,
jobs, ar d personnel of the area
k'
their own role and that of
the other team members.
Have trust and confidence in their
colleagues, respecting their
knowledge and skill.
Be aw.ire of the other inter-
HI.AI.I H<SA»in lEAMHOKk
disciplinary health personnel
resources available to them.
Consult and collaborate? with e?ach
other as needed.
Keep either team members in
formed.
Since each of our 14 teams operates in a
style: established to meet the needs of its
area. 1 will attempt to outline the* nursing
ami secretarial roles as a composite picture.
The secretary is the administrative team
member, responsible for scheduling and
coordinating activities by working with the
physician, nurse, and area management to
provide the maximum utiliz.ition of time for
all concerned. The secretary maintains
records, assures their availability to the
health professionals, is the first line of con
tact with the departments, and fields ques
tions to the approp:late team members. The
secretary is a key person in establishing an
atmosphere of cooperation and team unity
The area nurse in collaboration and con
sultation with lhiK physician working by ap
pointment from «in office preferably near
the area physician—performs pre-placement and hea’th hazard examinations:
periodic physicals: sees patients with self
limiting illness; follows progress of people
with occupational injuries: teaches health
maintenance; counsels individuals with
emotional, family or absentee problems
referring them Io the family physician or ap
propriate community agency when needed;
and follows persons with chronic illness, in
conjunction with their family physician,
helping the individual to manage his ill
nesses on the job. The area nurse also par
ticipates in organizing health surveys and
develops or participates in he.illh education
programs for the area, such as breast selfexamination and diabetic information ses
sions.
In the absence of the area physician, the
nurse is the department's contact with the
Medical Department. She or he follows
through on problems, consulting with the
necessary health care profi*ssionals—physi
cian. industrial hygienist, toxicologist, visit
ing nurse, human factors group, and private
/<>
.. .. r, ______ __ _______________ _
physician—to obtain necessary information
for the department or to initiate appropriate
treat muni or action, consistent with the
scope of the nurse’s extended role.
The nurse’s role at Kodak Park has also ex
panded in the dispensary operation. Our
people have two avenues to the Medical
Department: they may make an appointment
to see the area physician or nurse, or they
may walk into the dispensary, which has
nurse coverage 24 hours a day. 7 days a
week. The nurse is responsible for making a
nursing assessment and plan. This is accomn’ished by interviewing: history taking;
performing regional examinations as indi
cated: ordering laboratory. ECG. and X-ray
studies: and evaluating the collected data
(excluding X-rays and ECG’s) as the basis
for a plan. The nurse may decide to treat
self-limiting disease with medication consis
tent with standing physician orders or in ac
cordance with standard procedures, refer
the individual to the family physician or
community agency, collaborate with the dis
pensary physician to draw on his or her ex
pertise to gain additional knowledge, or
have the person seen by the dispensary
physician for X-ray and ECG interpretation
or medical diagnosis. We feel the setting
offers unlimited opportunity for continuing
education and teaching. Physicians are al
ways willing to demonstrate, to counsel, or
instruct. The nurses are eager to increase
their knowledge and ability.
In the dispensary, the nurse uses the inter
disciplinary approach in many other ways.
For example: she informs the safety depart
ment when she becomes aware of a serious
injury or unsafe condition in the plant, and
they may contact the supervision or the an*a
health team before writing a job restriction
to insun* that the prescribed conditions an*
feasibh*
The oc'.upational health nurse takes advan
tage of every opportunity to do health teach
ing, and to provide health guidance to
employees. Since tlx* dispensary service is
intended to respond to immediate medical
77
needs, we believe complex or chronic prob
lems should be followed by the ar<*a team
physician or nurse, who have a more com
plete picture of the work environment. The
team can develop better continuity of care
and rapport with the individuals.
The dispensary nurse communicates to the
area team physician and nurse any unusual
health situations or potential health problem
w’ith a person in their area, and refers ap
propriate cases or pertinent information to
them. In addition, the nurse continues to ad
minister first aid and treatment to anyone
coming into the dispensary, as well as
following progress of minor occupational in -J
juries until full recovery.
A committee is currently studying how a
health appraisal team would function. When
implemented, it is anticipated that the nurse
will he the on-line professional. The nurse
in this capacity will participate in the
development of the operational objectives
and evaluation of the service. He or she will
obtain histories, perform examinations, con
sult with the area team to identify groups to
be examined and examinations to be per
formed. 'Fhe nurse will work with techni
cians and the clerical staff to a* sun* accurate
data is reported to the area team for their ap
praisal and follow-up.
A committee is also studying the Medical
Department’s role in rehabilitation. In the
event of serious illness or injury—early, ac
tive. specific intervention with a stated
rehabilitation plan formulated by the area
physician and/or nurse should include con
sultation with the personal physician and
the Medical Department's rehabi’itation
consultant. We feel the Visiting Nurse
should play a vital part in this team’s effort,
evaluating the home* situation, progress,
motivation, and adh(*rence of the patient to
the plan. This would include counseling and
advising on methods. equipm<,nt. and man
agement of the individual's illness and com
munity resources, working with the area
team and the rehabilitation consultant, and
helping the area team evaluate th; plan and
the individual's progress.
HEAI.TH/SAfrTT> TEAMllORK
CONCLUSION
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While there are many areas in which the
nurse may function independently, provi
sions should be made for medical supervi
sion. This does not mean to say that the
nurse is not fully accountable for his or her
actions and totally committed to the ethical
standards and scope of nursing practice.
Communication lines for consultation and
collaboration between the interdisciplinary
team members should be established and
maintained. Utilization of each other’s pro
HE.Al.TH'S.Aff 7 > TEAMM ORK
fessional skills not only enhances the oc
cupational health service provided, but in so
doing, assures nurses and other team mem
bers increased job satisfaction knowing
their expertise is being utilized more com
pletely.
REFERENCE
1 "A Guide for Ihe Preparation of a Manu«<i of
Policies and Procedures for Ihe Occupational Health
Services," American Association of Industrial Nurses.
Inc.. New York. 1969.
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INDUSTRIAL HYGIENE. WHAT IS IT?
THE INDUSTRIAL
HYGIENIST’S
VIEWPOINT
According to the American Industrial Hy
giene Association. "Industrial hygiene is
that science and art devoted to the recogni
tion. evaluation, and control of those en
vironmental factors or stresses arising in or
from the work place which may cause sick
ness. impaired health and well-being, or sig
nificant discomfort and inefficiency among
workers or among the citizens of the com
munity." The three key words in this defini
tion are "recognition.” "evaluation." and
"control." Thus, by definition, industrial hy
giene includes studies on chemical hazards
such as gases, vapors, dusts, fumes, and
mists: physical hazards such as ionizing
radiation, lasers, ultraviolet light,
microwaves, heat. cold, and noise in the
working environment and. in addition, air
pollution and noise within the community.
Franklin A. Miiler
How does an industrial hygienist recognize
a potential health problem in the plant?
Some of the means are:
Industrial Hygiene Inspections During an
industrial hygiene survey or while doing a
job in an area, an industrial hygienist will
note conditions that should be investigated
further.
Safety Inspections Safety personnel on a
routine inspection of a plant may note con
ditions which they feel might be a potential
health hazard. These should be called to the
attention of the industrial hygiene group for
action on their part.
Government Inspections Federal or state
inspectors visiting the plant will issue cita
tions if conditions exist that they feel do not
meet health standards. These citations will
normally be referred to the indust.~ial hy
giene group for follow-up. Also in the realm
of governmental control we must now face a
multitude of criteria documents and a
deluge of ‘ Mini-Standards" being written
HEALTH/SAFtm- TEAMWORK
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under the Standards Completion Project.
These documents are a prelude to standards
that may spell out in detail medical, safety,
and industrial hygiene work that must be
done for an industry to be in compliance.
Visits to Plant Medical Department A per
son who has become ill might make a visit to
the Medical Department. The physician or
nurse should find out the reason for the
problem: and if it is a chemically induced ill
ness. the industrial hygiene group will be re
quested to investigate the problem.
Plan! Physician The plant physician, who
through inspections of the plant has become
familiar with the working conditions, can re
quest an industrial hygiene investigation to
documem contaminant levels around a cer
tain process.
Operator Complaints A worker may find
his job disagreeable because of odors or ir
ritation to his respiratory tract. His com
plaint to a supervisor or a safety representa
tive would in iurn be reported either to the
plant medical department or to the industrial hygiene group.
In this situation, one must consider the
difference between individuals. What may
be regarded as only a barely perceptible
odor by one may be considered as strong
and objectionable bv another. Also, many
vapors when continuously inhaled fatigue
the sense of smell, making the use of odor as
a warning signal unreliable or ineffective.
The first step in evaluation is to determine
the concentration of contaminant to which a
worker is exposed. Sometimes one can
judge that concentrations are so low (or
high) that quantitative measurements are
unnecessary. However, in most cases the
evaluation is done by sampling the
workroom air for the known contaminant or
contaminants It is very critical, no matter
how accurate and precise the analytical pro
cedure. that a representative sample is col
lected to determine.what the operator is ac
tually breathing. Therefore, samples are
taken as close to his breathing zone a . possiHEAL7t</SAFE-n TE.AMW()Rk
ble. While at the work place, data are col
lected to determine the amount of chemical
usage, exposure time, and number of
employees exposed. Also, observations are
made of handling procedures, housekeep
ing. and potential skin contact. This is
necessary because, although the primary
mode of entry of the contaminant into the
body is the respiratory tract, contaminants
can and do enter the body through ingestion
and skin absorption. All this information is
necessary if an accurate assessment of the
operation is to be made, and it should aid the
industrial physician in reaching a proper
decision as to the safety of this working en
vironment. Evaluation, therefore, may be J
defined as ‘he decision-making process
which establishes the degree of health
hazard from chemical or physical agents in
the industrial environment.
industrial hazards can be controlled in
various ways. These include:
Substitution This simply means substitut
ing a less toxic agent for the one in use. In
doing this it must be determined if the new
agent is compatible with the process. Also,
consideration must be given to the amount
oi agent required and the difference in
physical properties (e.g.. vapor pressure) of
the agent. These last two considerations may
negate any benefits derived from the
substitution.
Local Exhaust Ventilation The exhaust
should be located as close as possible to the
contaminant source in order to most effec
tively control environmental concentration
of the contaminant. Preferably, a competent
ventilation engineer should design the
system and check it after installation to be
sure that it complies with all necessary
regulations. Routinely thereafter the system
should be measured to be certain the air
flow is operating according to design
specifications. It should be remembered that
local exhaust ventilation provides control
with relatively small quantities of exhausted
air.
General Ventilation Good general room
ventilation is only adequate in certain
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limited cases, e.g.. with solvents of low tox
icity that are used in small quantities. The
degree of hazard can be determined by con
sideration of the number of air changes per
hour in the room, the room size, and the
amount of solvent used per hour.
Job Rotation This simply means rotating
operators so that their time-weighted
average exposures do not exceed standards.
This is not a particularly good method of
control because of the problem of schedul
ing the labor force and the necessity of hav
ing another job available where there is no
chemical exposure.
Improved Housekeeping and Handling Pro
cedures It should be obvious that if chemi
cals are dumped or spilled on the floor and
over the machine, the chance of over-ex
posure is much greater than if the operation
is carried out in a neat and tidy manner.
Sometimes poor housekeeping is not all the
operator's fault but is the result of over
crowded conditions in an area. It is then a
supervisory problem to correct this over
crowding.
Personal Protective Equipment There is a
wide variety of personal protective equip
ment such as respirators, gloves, face
shields, plastic aprons, plastic gloves, and
boots. This type of control is considered as a
last resort measure except, of course, in an
emergency situation. It is unreasonable to
expect a person to be required to wear
respiratory protection, for example, for the
entire workday or even routinely for shorter
time periods. The situation should be cor
rected by one of the other mentioned
methods.
potential hazards of the materials they are
working with, they will be encouraged to
use protective devices that are supplied.
Various techniques include slide/tape talks,
written standard practices which the opera
tor must read and follow, and demon
strations of the value of good housekeeping
and handling procedures.
In order to carry out a good occupational
safety/health program, it will be essential to
have available the services of the following
disciplines:
Toxicologist The toxicity evaluation of
chemicals that are encountered in the plant
is needed to determine the relative hazards
of the chemical agents.
Health Physicist Ionizing radiation
sources are in widespread use in many plant
operations: thus health and safety aspects cf
these sources is best determined by a person
trained in health physics.
Chemist The analysis of samples taken in
the plant must he accurate and precise if one
must rely on the results to reach a decision
concerning a possible health hazard in the
plant. Also, as new chemicals are in
troduced into the plant, new analytical pro
cedures may be required. The analyt'cal
chemist is able to develop these methods.
Safety Engineer This person can be very
helpful if. during his safety inspections, he
notes any health problems and brings them
to the attention of the. industrial hygiene
group. Also, by working with the industrial
hygienist and the industrial physician, (he
safety engineer can help to implement pro
grams that will improve working conditions
in the plant.
Enclosure Completely enclosing a process
or piece of equipment is another means of
reducing human exposure. This has been
successfully used on noisy pieces of
machinery and also can be used on chemical
emissions in conjunction with local exhaust
ventilation.
Physician The final decision as to the po
tential health hazard of an operation is the
physician's responsibility. This decision is
based on both knowledge of the operation
and the data supplied by the industrial hy
giene group.
Education of Workers This can be very
successful. By educating the workers Io the
Human factors Specialist This person
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specializes in the design and layout of a pro
cess to minimize stresses caused by lifting,
reaching, and bending.
Design Engineer He is called upon to
design the proper local exhaust ventilation
and to check and balance the system after
installation. In addition, he should work
closely with human factors people in the
design of a plant layout.
Nurse Though nurses may not be familiar
with a particular plant operation, they can
aid in determining if a visit to the medical
department may be due to a chemical ex
posure in the plant. This information can
then be passed on *g the physician and the
industrial hygienist
Industrial Hygienist The industrial hy
gienist is needed to take samples and also to
gather the necessary data for the complete
evaluation of an operation or process. Based
on the analyses and the information
gathered from the process or operation dur
ing sampling, the report will aid the physi
cian in determining the potential hazard of
this operation or precess.
Up to this point we have considered only
"firefighting” situations: that is. trying to
correct a problem on an existing process or
operation Although this aspect of industrial
hygiene will always exist, an attempt should
be made to institute a preventive occupa
tional health program. One approach to the
preventive program is through the use of an
environmental health team. This team
would include representatives of the various
disciplines including a physician, an in
dustrial hygienist, a human factors
specialist, and a safety engineer.
The objectives of this multidisciplinary team
would be to:
1.
2.
Determine if there are any actual
or potential health hazards in the
work environment.
Create a knowledgeable health
force that is familiar with all plant
activities and that can advise man-
HEAI.TH/SAJ ETV TEAMVk •')Kk
3.
agement in maintaining a safe
work place.
Make recommendations to man
agement concerning health
hazards, periodic monitoring
needs (people and environment),
and record maintenance.
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The team would conduct surveys, evaluate
new equipment and new processes. Its in
itial task would be to conduct a walk
through survey within each plant area; this
would be followed by a series of surveys by
each team member who would concentrate
on those matters related to his specially. Of
particular concern should be areas that are
prone to have:
Physical or behavioral problems
Excessive noise
Poor illumination
Excessive heat
Inadequate ventilation
Restriction of individuals who can per
form the job
Awkward posture (man/machine in
terface)
Radiation exposure (ionizing and non
ionizing)
Excessive vapor and dust exposure
i
P should be emphasized that this list is not
intended to be all inclusive. The results of
these surveys will be useful in the planning
of both short- and long-term improvements
of each plant area’s working environment.
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After this initial survey, the team should be
familiar with operations and processes and
«ilso be aware of any potential health and
safety problems. In the event of changes in
operations and/or installation of new equip
ment and processes, plant management
could meet with the environmental health
’earn to review th? impact of the changes,
'i he design engineer should be included so
he can review his proposed plans with the
team and then revise these plans in view of
any suggestions that might be made. This
type of approach would help the plant man
agement be more aware of their respon
sibilities as a result of the changes, and it
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would also help the team keep abreast of
changing operations within the plant.
Where can one go for professional industrial
hygiene assistance if your plant does not
have an industrial hygiene group? This is
perhaps the case in a majority of small in
dustries. One excellent source of help is
your insurance carrier: many carriers have
an in-house staff of hygienists or o her
health specialists. Another source is pro
vided by listing of consultants and is availa
ble through the American Industrial Hy
giene Association’s business office in
Akron. Ohio. This office also has available
for sale many publications relating to the
field of industrial hygiene. These include
manuals on noise, analytical methods,
monographs on various subjects, and a hy
gienic guide series.
Books are another excellent source of infor
mation on industrial hygiene. Some sugges
tions are:
1. Brandt A. Industrial Health Engineer
ing. John Wiley and Sons. New York. 1947.
2. Industrial Hygiene and Toxicology.
Frank A. Patty (ed.) Interscience Publishers.
1963.
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3. Jacobs MB. The Analytical Chemistry
of Industrial Hazards. Poisons, and Sol
vents. Interscience Publishers. 2nd ed. 1949.
4. Occupational Medicine: Principles and
Practical Applications. Carl Zenz (ed.). Year
Book Medical Publishers. Inc.. 1975.
One final suggestion is your local safely
council which is affiliated with The National
Safety Council.
I have tried to point out that an occupational
health program relies on many different dis
ciplines. and the most successful program
utilizes each of these disciplines to ac
complish the primary objective of a safe and
healthy working environment.
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MEDICAL RELATIONSHIPS WITH
UNIONS AND MANAGEMENT
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AN OCCUPATIONAL
PHYSICIAN’S
VIEWPOINT
Alexander L. Strcisser. M.D.
As the health advisor to management, the
occupational physician interrelates with the
local union leadership on all matters per
taining to cccupational health and safety. It
is vital for the success of any occupational
medicine program that a spirit of coopera
tion exist between the occupational
medicine department and the local union.
This lesson is a difficult one for new occupa
tional physicians, as labor relations have
never been emphasized in occupational
medicine or traditional clinical programs.
The purpose of this paper is to outline areas
where occupational physicians and
organized labor interact and to show how it
is in the interest of all parties that medicine
and labor work together for the common
benefit of the working man and woman. In
their everyday duties, the occupational
physician and local union steward have
many points of contact. Some of the more
important areas are the following:
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1. Medical Absenteeism
Accident and sickness insurance
(group insurance}
Workers’ compensation insurance
2. OSHA Compliance
3. The Role of the Union Steward and the
Supervisor in Health and Safety
4. Industrial Hygiene and Toxicology
5. Health Insurance
6. Medical Limitations and fob Restric
tions
7. Confidentiality of Medical Records
fl. The Occupational Physician and the
Local Union Leadership
9. Alcoholism
10 The Labor-Management Agreement
and the Occupational Physician
11. The Ethics of the Occupational Physi
cian
Medical Absenteeism When it comes to
medical absenteeism, the occupational
physician is the person who must interrelate
between the patient (employee), supervisor,
union, and personal physician. Short-term
VNIONIMANAGEMEST
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illnesses are often treated in occupational
medicine departments and rarely cause any
problems. It is in the area of long-term ill
nesses and injuries that conflicts are more
liktdy to arise.
The etiology, diagnosis, treatment, and pre
vention of disease has received much atten
tion in medical education. There has been
little effort to assist the physician i.r deciding
how long an ill or injured employee should
stay out of work. Specific guidelines are ab
sent: and in many parts of the cor '-y. pa
tients are kept out of work for varying
periods of time for the same illness.
When a difference of opinion arises be
tween the company, medical department,
and private physician over the length of a
sick leave, the union steward and labor rela
tions renresentative are contacted. Here the
attitudes of labor, management, and the oc
cupational physician become most impor
tant. While it is easy to agree with the
philosophy that "sick pay is here to be used
and not abused.” it is in the specifics that
agreements break down. How long should
an employee with a cold stay out of work?
When should an employee return to work
after hernia surgery? The attitude of the
company and union are influential in deter
mining a return -to-work date. If there is fric
tion between company and union, a sick or
compensation leave could become the vehi
cle for an extensive legal disagreement lead
ing eventually to a final decision by the Na
tional Labor Relations Board (NLRB).
It is not necessary for a case to go to the
NLRB for controversy to arise. The attitude
•'you have X number of sick days corning,
use them.” could foster controversy between
the local union and management. Many
companies have a negotiated number of sick
days that have been agreed upon at contract
time, and how these sick days are used is a
good barometer of the company-union rela
tionship.
Medical absenteeism can be divided into ac
cident and sickness insurance (group in
surance) and workers’ compensation in
surance. Let us first look at group insurance
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and see how medical relationships between
union and management are involved.
Accident and Sickness Insurance In a 16article series on Medical Absenteeism that
appeared in The Bulletin of the Monroe
County Medical Society. 1 pointed out that
motivation is the most important factor in
determining when a sick or injured
employee returns to work after a sick leave.
Other contributing factors are the type of
work the patient is doing: the altitudes of the
supervisor, labor, and the personal physi
cian: the basic health of the patient: the type
of insurance coverage available: and the dis
ease entity.
Both labor and management have a stake in
the proper administration of group disability
programs. It has been estimated that for ev
ery dollar spent on sick pay. a company
loses S10 in lost productivity. It is thus easy
to see why management does not want sickpay programs abused. Labor also is in
terested in medical absenteeism. Unions
want to make certain that fringe benefits are
used when needed and that sick pay plans
stay solvent. Neither responsible labor nor
management wants to see sick-pay pro
grams abused, as such action needlessly
drives up the cost of doing business and
could lead to logs of jobs anti lowered prof •
its.
Workers’ Compensation Insurance
Workers' compensation has been a tradi
tional area of conflict between labor and
management. Originally devised as a
method of compensating injured employees,
workers'compensation has been both an in
centive for business to improve safety prac
tices. and a form of "social legislation."
The definition of a workers' compensation
case is simple in theory but complicated in
practice. An employee who falls at work or
gets his fingers caught in a machine ob
viously has a work-rela’ed injury. Whether a
groin (inguinal) hernia is work-related or
not is not always easy to decide. Most states
do not mandate accident and sickness in
surance. and the employees may not be
covered by group disability insurance. Since
I-MOMMAS’MIEMEST
a workers' compensation case is usually
a.ore rewarding to an employee than a
group disability claim, it is in the economic
interest of the employee to file a workers'
compensation case if there is any doubt as to
whether his illness or injury is work-related.
A common example would be the employee
who does heavy lifting at work and develops
an inguinal hernia without remembering a
particular incident that brought his attention
io the nernia. Most inguinal hernias are con
genital and art* not related to physical stress.
. Unions have often taken the position that an
employee with an inguinal hernia who does
he.ivv lifting automatically has a workers
compensation case. Management finds this
difficult to accept. Many times an employee
will do heavy lifting at home, and business
a”gues that the hernia could as easily have
occurred from an injury at home.
Low back pain is another common problem
spen in industry. Most of low hack pain is
due to discogenic bar k disease.1 If an
employee does heavy 'ifting at work and
develops a “slipped disc." does this mean
the heavy lifting caused the slipped disc? If
th<- employee cannot recall a particular inci
dent when he "hurt his back.” management
may not voluntarily accept the back disorder
a:; woi k-related.
Workers' compensation questions still pri
marily deal with safety problems and workrelated injuries. Recent advances in tox
icology. however, have brought the question
of work-related illnesses more into the
forefront.
In today's complicated society, every Ameri
can is exposed to many different chemicals
in his daily life. There are chemicals al
Wurk. school, in the home, in the food we
eat. and even the chemicals exposed to al
play (swimming pools, and so forth). I here
are thus multiple exposures to potentially
troublesome materials. If one of these subsUmues does cause an illness (and this is not
always known with any degree’ of certainty),
then there still is the question of the possible
etiological effect of the other chemicals to
which the individual is exposed.
In times of economic decline, it becomes im
portant to an individual employee whether
or not his medical problems are ruled workrelated. Lay-offs go by seniority, and many
company-union contracts have provisions
that give employees with occupational ill
nesses or injuries “bumping rights" that
may help then: keep their jobs.
When an employee is permanently unable
to work due to a medical condition, there are
two routes that he can go to collect benefits:
Medical disability under scxaol security
Medical disability under workers’ compen
sation
Employees may collect social security
benefits before reaching the age of 62 when
they are medically unable to work. Any
medical condition can qualify an employee
for total and permanent disability if his per
sonal physician and the social security office
agree that the employee is unable to work.
An employee can also apply for total and
permanent disability under workers com
pensation. From an economic standpoint, it
does not make that much difference to the
individual which route he goes for disability
retirement. For industry, however, this is an
important decision. Under workers com
pensation, the insurance company (meaning
the employer) pays for the benefits, while
under social security, the payments come
from the social security fund (not all from
the employer). Many times there are major
disagreements between company and union
over the issue of disability retirement, in
such a situation, the occupational physician
can play an important role in helping the
company and union reach an equitable
agreement on which way the particular case
should be handled. While there is always a
legal pathway to handle disputes, it is in
everyone’s interest to have the disagreement
between company and union settled be
tween the two parties without having the
case go to a third party for decision.
OSH A Compliance The passage of the Oc
cupational Safety and Health Act in 1970
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was brought about in great part by the com
bined efforts of organized medicine and
organized labor. The occupational physi
cian. working through the American Medi
cal Association, the American Occupational
Medical Association (then called the In
dustrial Medic it Association), and other
professional groups, was in the forefront of
the effort Io secure meaningful legislative
changes that would help make the work
place as safe and free from hazards as is
humanly possible In no other ari'a do the
interests of labor and medicine coincide as
clearly
OSH A brings together the occupational
physician, labor, management, and govern
ment in a joint effort Io improve working
conditions As with anv regulatory agency,
the possibility for an adversary situation ex
ists: and in those plants when' labor-man
agement relationships are bad. OSH A can
become a politic.il football. Likewise. OSH A
can bi' used as an impetus to improve work
ing conditions and thus lead Io a reduced in
cidence of occupational illnesses and in
juries.
Despite the recent emphasis on environ
mental hazards, most OSH A violations are
still in the area of ' bread and butter” safety
lapses. Unguarded machines, violations in
walking and work surfaces, rails ladders,
signs, steps, improper utilization of machin
ery are the infractions most often cited. Here
the local union steward is in a position to be
of help to his fellow employees. If a union
steward knows of a safety infraction, he
should bring it to the attention of supervi
sion for action.
The Role of the Union Sk . d and Super
visor in Health and Safety OSH/X regula
tions clearly define management s respon
sibilities in areas of health and safety. 11 is
the foreman's responsibility Io ensure that
these obligations are met. Employees should
be personally instructed by the foreman in
proper safetv procedures, and hazards
should be immediately corrected.
In fa< t<»ri<‘s where good rapporl exists be
tween management and labor, the first-line
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supervisor and steward cooperate in in
specting the area for health and safely
hazards. Where appropriate, protective
equipment Is required such .is safety
glasses, respirators, ear plugs, and so fort’.i.
’There is always a certain amount of reluc
tance by some individuals to use safely
equipment, as is manifested by the public's
failure to ' buckle up” their seal bells on the
roads of this country. The support of the
local union steward is most helpful in get
ting the employees to wear and use protec
tive safely equipment.
When an tmiplnyee violates a safety rule, the
altitude of the union steward beconuts par
ticularly critical If he supports the fore
man's effort to stress safe work pretJues.
them future accidents may be averted. II is
also important for the foreman to try to edu
cate the workers to follow good safely prac
tices. and together with the union steward,
to prevent safety and health from turning
into an area of controversy.
In many companies, health and safety has
unfortunately become an issue of conflict
betw’een management and labor. When this
happens, the occupational physician can
serve as a catalyst to bring management and
labor together io work for the common good
of ail the employees, be they represented or
unrepresented. Neither management nor
labor should monopolize health and safely.
There is plenty of opportunity for both
groups Io make contributions in occupa
tional medicine.
Industrial Hygiene and Toxicology The
occupational physician must be well
grounded in the principles and applications
of toxicology and industrial hygiene. Tox
icidogy is primarily concerned with the
physiologic effects produced in individuals
exposed to harmful materials. The toxicity
of a material is not svnonymous with its
work hazard Toxicity is the capability ol a
material to produce an injury or harm. whd<hazard is defined as the possibility that a
materia! will cause injury or harm when an
individual is exposed to a specific quanlitv
of a chemical under specified londitinns
Toxicity is primarily dependent on dose.
rate of dosage, site of absorption, general
state of health, temperature, and individual
variations. The industrial hygienist is the
health professional who moni’ors the en
vironment for toxic agents. He works with
the occupational physician in trying Io make
Iht work place safe and h' . hv for all
employees.
Recent concerns about the environment
have highlighted the importance of in
dustrial hvgiene and toxicology. Many
Americans are employed in a work setting
that is minus the services of an industrial
hygienist. It is therefore left to the occupa
tional physician and safety professional to
perform the functions of the industrial hy
gienist. Most labor unions do not have?
available? the consulting services of an in
dustrial hygienist. This lack of expertise can
be looked upon as both a detriment and an
asset. Obviously it would be good to have
available the services of an industrial hy
gienist where such a need exists. On the
other hand, the absence of the induslri.il hy
gienist can be used by labor and manage
ment as another reason to work together foi
the common good of the employee and tne
company. Good health practices an* good
business, and this is not alwavs appreciated
by all concerned parties
In many inelustr:e*s. management and labor
have* cooperate*d on a more* formal basis. Oc
cupational physicians often make periodic
tours together with the safety professional
anel management re^pre’semtatives from plant
enginee*ring and manufacturing. Union
stewards are? also known Io make* lhe*ir own
safety tours. Problems discovered in such
tours are* then corre*cte*d. and a better basis
of understanding be*tw<?e?n management and
labor results.
Health Insurance Fringe benefits make uo
about one-third of an employee's salary in
many companies, and health insurance
comprises a major part of the benefit plan
Ten years ago. a major company paid about
15 i.enls an hour per employee for health
benefits. This has now risen Io about 75
cents an hour. It is easy to see why labor and
management are interested in health in
surance. Both labor and management can
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seek advice from the occupational physician
when it comes to questions on health in
surance. It is therefore incumbent upon the
occupational physician to keep up-to-date
with health insurance developments in his
area.
In addition to traditional fee-for-servii.e
medicine and major medic.d insurance, in
duslry is now faced with many alternatives
of health care that have been labeled under
thi* general title of Health Maintenance
Organizations Under this heading are
closed panel prepai I group practice plans,
medical foundations, indepi'ndenl practice
association (HMO’s without walls). What
should the attitude of labor and manage
ment be towards these* groups? rhe* provi
sions of the* 1973 HMD Art will be followed,
but in addition to this, the occupation.il
physician is in a position to advise labor and
management about the* quality and (pialificationsofthe particular HMO where the busi
ness is located.
Most Americans are covered bv some form
of basic health insurance. This usually in
cludes hospitalization, surgical and inpa
tient medical care, and main contain a ma
jor medical provision There may be options
for drug riders, laboratory riders, outpatient
X-ray coverage, and so forth.
Dental care has only recently received atten
tion at the bargaining table. While still in
their infancy, dental plans promise to
multiply in the near future. Plan design and
efficient claims control procedures an* im
portant so lha* the dental plans are not over
burdened at the onset from a pent up de
mand for dental can* To this end. the oc
cupational physician is in a good position to
influence labor and management and help
guide them to the best dental plan for the
most number of employees.
Then* has berr some discussion about mak
ing occupational medicine departments into
HMO's. and this has brought the occupa
tional physician into the* limelight of the
HMD controversy Traditional occupational
medicine departments have* t.iken t are* of
those* employees suffering Irom oceup.iliemal illnesses and injurie*s. and referreel
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non-eccupational medic.ine problems to the*
Medical limitations can bt'come an area of
personal physician of the employee. In (’lass
dispute between management, labor, and
I and II occupational medicine? programs.the* occupational physician has treated some?
the occupational physician. A limitation can
have the effi’ct of forcing an employee out
se*!f !mited non-occupational illnesses and
injuries anil rcferreel those cases that re
on a lay-off or result in his or her being
transferred to a lower labor grade with a
quire* ongoing medical care* to the private*
resultant reduction in pay. When this hap
practice* sector of the me’dical community.
pens, the union steward may be brought into
the case by the employee*.
Some • xamples of those* types of non-occupational illnesses and iniuriecs taken care*
of by the occupational physician would be* a
streptococcal pharyngitis. viral upper
respiratory infection, colds, sprains, contu
sions. pulled muscles, and so forth. Patiemts
with complicated medical problems, such as
diabetes mellitus. conge stive heart failure,
cancer, collagen elisease?s. and so forth,
would be referred to their personal physi
It may be helpful to look at some* common
cases where* me’dical limitations can bring
about
interaction
between
the*
union
steward and the occupational physician. If
an employee? has a back disease, a me dical
restriction may have* to be? imposed limiting
the? amount of lifting and bending the?
emple)ye*e? can do. Should the* job demands
go beyond the restriction, then the employee*
cian for can*.
would not be allowed to perform the? job.
and he? would have* to be? transferred to a
Occupational physicians as a group have
different job. Depending on seniority, the?
employee would the?n find himself in
generally resisted efforts to make occupa
tional medicine departments into HMO’s.
There an? many reasons for this. 11 was
never the intent of occupational medicine to
compete with the private practice sector of
the medical community. The occupational
physici m has sought to supplement rather
than replace the personal physician. In the
early 'lays of occupational medicine, some
occupational physicians did take care of the
eni re worker populations in some factories.
Most occupational physicians look at this as
captive medical care and as being against
the basic principles of free choice of physi
cian md hospital that they feel every worker
should have. For these reasons, there has
been a genuine? reluctance for occupational
physicians Io convert their medical depart
another job or possibly on lay-off.
Another case? in point would be? an employee
with advanced, progressive? rheumatoid
arthritis. If such an employee? is no longer
able? to do fine* wen k with his hands, then a
medical restriction would have* to be* placed.
Not only must one? consider the* employee's
ability to perform the? job from a nwdical
standpoint, but one? must also take? into ac
count if the? employee’s illness would result
in his actions affecting the health of his
coworkers. An employee with advanced
rheumatoid arthritis and poor grip in his
hands would not be allowed to work with
dangerous acids o*' chemicals for fear he
may inadvertently hurl himself or others.
ments in io HMO’s.
Whenever there is a dispute over a medical
Medical Limitations and Job Restrictions it
is not uncommon for an employee to have a
medit d problem rmpiiring the placing of
medical limitations. Some examples of
medzcai limitations would be the following:
/\n employ<*(* with an uncontrolled
seizure disorder would be prohibited
from driving a power vehicle.
An employee who is colorblind
restriction, liaison between the union,
employee, management, and occupational
physician becomes most important. The?
employee’s personal
physician
contacted, and his opinion
is always
and advice
solicited. When comp.my amt union cannot
agree on medical restrictions, the dispute
can end up in arbitration. The Litter step
should not be necessary when labor, man
would not be allowed to do work re
agement. and the occupational physician are
able to have an open and meaningful
quiring critical color vision.
dialogue with one another.
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Confidentiality of Medical Records The
confidenlialitv of the medical record is as
sacred to the occupational physician as Io his
counterpart in private practice. When a pro
perly executed medical record release form
is completed, then medical information can
b(‘ freely disseminated through the ap
propriate channels. OS! IA regulations on
medical records tire dearly spelled out and
cause no particular problems.
There are occasions when company and
union representatives need to h ive some
medical information in order Io be able to
settle disputes between employees or be
tween labor and management. Examples
would be controversies over medical restric
tions. sick leaves, workers' compensation
leaves, working h«d>its. to mention a few
areas. Whenever possible, the occupational
physician should supply only general parts
of the medical record th.it do not invade the
privacy of the employee. When confidential
information is retpiired, then written per
mission should be obtained.
Industry is responsible for the health and
safety of its employees, and management
cannot allow an employee with a medical
impairment to perforin a job that would be
dangerous to his fellow employees. The oc
cupational physician will ill times have to
discuss some pans of the medical record
that could have a negative impact on the
employee s ability to hold or perform a cer
tain job.
It should be emphasized that those cases re
quiring the discussion of the medical
records with company and union represen
tatives are rare, and every effort must be
made by the occupational physician to
safeguard the privacy of the medical record.
The Occupational Physician and the Local
Union Leadership Relationships between
organized labor and organized medicine
have been marked by misunderstandings
for many years. The occupational physician
has been greeted with a great deal of caution
and misgivings by organized labor. The
phrase "companv doctor" has come to mean
to some labor leaders that management
"owns" the occupational physician While
there are a few bad apples in every barrel
and in evt*ry profession or group, occupa
tional physicians have resisted the label of
"company doctor" as they worked hard and
diligently to establish occupational medicine
as a separate and distinct subspecialty of
preventive medicine. In 1955. occupational
medicine was finally recognized by the
American Board of Preventive Medicine as
a new specialtv. A special occupational
medicine training program was set op. and
professionalism in occupational medicine
was encouraged
Whether the occupational physician is
employed full-time in industry or serves as a
consultant to local industry while maintain
ing a private practice in the community, it is
important that th<‘ occupational j.hysician
encourage contact and liaison with the local
union officers and stewards. An open-door
policy will lead to dialogue between the
union leadership and occupational physi
cian and result in the sfMtlement of disputes
before they reach the rigid confines of ar
bitration. While some cases may e» cntualiy
go to the National Labor Relations Heard,
most areas of dispute can be amiably settled
if a sincere effort is made? by both parties to
arrive at a fair and equitable solution.
The basic goals and objectives of the occupa
tional physician and union leader are to
assist the employee and to be of service to
the workers. With the employee’s welfare al
ways in mind, disputes between the occupa
tional physician and local union leadership
should not be a frequent occurrence
Alcoholism Alcoholism is a common
cause of medical absenteeism in industry.
Since such general terms as "nervous reac
tion.” "nervous agitation." "emotional
fatigue." and "anxiety syndrome" are often
used by the attending physician Io describe
symptoms of early or potential alcoholics on
group insurance forms, th<? true incidence of
alcoholism in industry is not known. Verv
often the signs of a drinking prol lem are not
visible when th** patient first sees his per
sonal physician.
'rhe problem of alcoholism is not uniqut to
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occupational medicine. Excessive drinking
loads to the deaths of 25.000 drivers on our
highways annually and to countless broken
homes and marriages. Writing in the Febru
ary 1973 issue of The /ournol of Occupotionof
Medicine. Pell and D'Alonzo reported on "A
Five-Year Mortality Study of Alcoholics"
that showed alcoholics who stop drinking
retain a considerable amount of excess mor
tality and morbidity (includes frequent ab
sence from work).3 Many alcoholics never
slop drinking, and those who an* able to kick
the habit appear to have a poorer prognosis
(medical outriok) than control groups. The
identification and treatment of the early or
"incipient alcoholic" therefore becomes
more critical in the prevention and control
of alcoholism.
Industry's approach to the alcoholic has
varied from company to company. Some
firms have taker, disciplinary action. Other
companies have encouraged the patient to
seek appropriate medical care, and some
businesses have just looked the other way
until circumstances make it impossible to
further ignore the problem.
The first signs of alcoholism are often noted
at work. The boss may notice that Joe leaves
early Friday and comes in late to work on
Monday. Joe's lunch period becomes drawn
out and the smell of alcohol becomes
noticeable on Joe's breath on returning from
lunch. Joe may start missing work due to
"colds." "nervousness." "stomach upsets."
and 'viral illness": and his work may start to
deteriorate. Joe may use the term "work
pressures" to describe his poor health to his
family and rationalize his excessive drink
ing the same way.
Because |oe still does his work, the boss may
be. reluctant to mention anything about Joe's
drinking. After all. "who doesn't have a
drink once in a while?" The paticmt. mean
while has excused his drinking as a means
of coping with his "nerves and shakiness.
Thus Joe's disease is overlooked until one
day his wife calls the boss to say that Joe will
be out of work several weeks. It may be at
this point that the diagnosis of alcoholism is
made and the occupational physician is con
tacted.
Tht etiology of alcoholism is not known,
although there are many theories. There is
no specific cure for alcoholism, but it is
possible Io keep alcoholics "on the wagon"
and thereby productive workers. The job
has <i hearing on how the company reacts to
alcoholism. A worker driving an industrial
truck or operating power equipmtml could
hart someone else by a safety lapse. Alcohol
is therefore entirely contraindicated on such
a task.
While lacking in psychodynamic theory, the*
company can use the incentive of the job as
a means to keep the employee off alcohol. Il
can bi? pointed out to the worker that if he
continues Io drink, he will lose his job: but if
hi? stops drinking, the company will do all it
can to assist the employee Io get over his
drinking problem. This type of approach is
simple, to the point, and most effective.
I lowever. the cooperation and support of the
local union is 100% necessary for this
method to succeed. If both the company and
union make it clear t) the drinking
employee that the price of continued drink
ing is loss of his job and that the reward for
abstinence is support of his efforts to gel off
the bottle, then the employee will have the
incentive to stop drinking. This approach
has been tried in several industries, and it
has worked very well.
The line between social drinking and
alcoholism is not a clear or fixed one and
varies from person to person. Many people
stay on the borderline of alcoholism for
years and never cross over: others become
frank alcoholics early in their lives and
never make it back It is clear, however, that
with the support of management, the oc
cupational physician, and the local union
leadership, the drinking employee has a
reasonable chance to bf? rescued from the
pitfalls of "alcoholism" and is able again to
become a productive member of the local
community.
The Labor-Management Agreement and
the Occupational Physician The com
pany-union collective bargaining agreement
is the document that sets the tone of manage
ment-labor relations for the duration of the
<'.MO-»7MANAGf.M»AT
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union contract. The occupational physician
(whether he be full-time or part-time) must
alsc li*.e by the spirit and th»* letter of the col
lective bargaining agreement. Unh'ss the
physician und' rstands the contents and
meanuigs of he union contract.’avoidable
mi’-uhderstandings will occur.
Most of the details of the collective bargain
ing agreement do not involve' the occupa
tional physician. In the past, the union con
tract was looked upon as something that "the
doctor did not get mixed-up in." Labor s
growing interest in health and safety has
resulted in increase’ll activities by unions in
areas where they interface with occupa
tional health anil safely ami has highlighted
the importance of a basic understanding of
labor relations by all physicians who are ac
tive in occupational medicine. "Bumping
rights’’ (ability of an employee to replace
ane.rher employee with less seniority in a
job) are bas’C to all collective bargaining
agreements. How a union contract spells out
"bumps" will inaki' a big difference in an
employees reaction Io a medical restriction.
It is thus important lh.it the occupational
physician has some basic understanding of
the union contract.
Whenever there is a dispute between the oc
cupational physician and the union over
medical absenteeism, group insurance, or
woikurs’ compensation matters, the union
c.ordiacl is looked to in an effort to find com
mon ground for a just solution. If the oc
cupational physician is not knowL’dgeable
of the union contract, he will be at a severe
disadvantage in dealing with labor and man
agement on matters affecting occupational
medicine. Even in matters traditionally
reserved to labor and management, such as
length i f work breaks, the occupational
phvsician may be asked for an opinion, and
he must therefore be cognizant of the basic,
fundamentals of labor relations.
The advent of OSH/X and NIOSH has
resulted in the occupational physician being
consulted when the union contract is negoti
ated. i he expertise of the occupational
physician can be invaluable in preventing a
clause from being inserted in the union con
( Mos
M.f Mt:vr
tract that both labor and in.ni.igcment would
have cause Io regret in the future
The Ethics of the Occupational Physi
cian Occupational medicine is one ol the
broadest, least understood, and most com
plex medical specialties. Il probably even
exceeds family practice and internal
medicine in its scope, depth, and complex
ity. /\n occupational physician must be well
versed in traditional clinical medicine He
must havi* a thorough background and un
derstanding of industrial hygiene, tox
icology. waier pollution, safety, preventive
medicine, administration, labor and in
dustrial relations, legal meilicine. workers'
compensation, government regulations, and
familiarly with OSH A and NIOSH Tb.e oc
cupational physician must be able to interact
with his colleagues in the private practice
sector and with the business and labor com
munity.
Most occupational physicians are employed
full- or part-time by industry, though there
are specialists in occupational medicine who
work for hospitals, educational institutions,
agriculture, civil service, and labor organiza
tions. The number of occupational physi
cians employed by unions in full-time or
part-time positions has been increasing re
cently. In addition, there are occupational
physicians who are ; elf-employed and who
do consulting work in industry.
Recent developments in toxicology have led
a few critics to question the ethics of the oc
cupational physician. Doctor William E.
Morton. Professor of Environmental
Medicine at the Univrrsitv of Oregon Medi
cal School, accused occupation.d physicians
of unethical practices in a ■ Letter to the Edi
tor’ published in 7'he lournol of Occupational
Medicine. Occupational physicians were ac
cused of withholding medical information
from publication in order to protect their
employers. Doctor Morton wrote that ’ most
industrial physicians identify strongly with
management fur socioh . ic.al and financial
reasons, and some may forget that the ethi
cal guidelines for the medical pio’ession are
more restrictive than for businessmen. 4
While every profession and group has some
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"bad eggs." Doctor Morton s doubts have
not been substantiated. Occupational physi
cians. like their colleagues in private prac
tice. are physicians first and take the ethics
of their profession seriously. What charge
could be more important than "to help make
the work place safe and healthy for all
employees”? Unfortunately, the unfavorable
publicity has led some labor leaders Io ques
tion lhe ethics of the occupational physician.
This has resulted in a "confidence gap" bet
ween some occupational physicians and
labor
Part of the misunderstanding that exists may
be traced to an unrealistic viewpoint on the
potentials of preventive medicine. There is a
good deal of evidence to show that medicine
has over-sold the capabilities of preventive
medicine in the health care field. Most of the
illnesses seen today are not preventable, as
we do not know the cause of most illnesses.
There are many theories' concerning the
etiology of vascular disease, heart attacks,
strokes, and cancer: but the exact causes of
these diseases are not known. Risk factors
have been identified that predispose to heart
attacks, strokes, and cancer; but at the pre
sent state of knowledge, prevention cannot
be guaranteed. The same can be said for
arthritis, diabetes mellitus, neurological dis
orders. inflammatory diseases, degenerative
diseases, and the common cold to mention
only a few.
Not only cannot the diseases alluded to
above be prevented, but we are often unable
to detect subclinical conditions predisposing
to disease states. If it is not possible io pre
vent disease entities in the general popula
tion. can we expect industry to do for its
employees what the personal physician is
unable to do for his patients?
If the occupational physician, labor leader,
and businessman are to work together, then
it is important that "emotionalism" be
deleted from the occupational health en
vironment. Occupational physicians have a
moral and ethical obligation to disclose any
medical documentation of human occupa
tional health impairment. Like their col
leagues in private practice, the occupational
95
physician is primarily interested in the
welfare of the individual. Whether th* in
dividual is called a patient or an employee
he is still a human being: and in ‘.he medtc-d
profession. th<* physician is here to serve
him.
REFERENCES
1. Rowe. M.L. "Low back Disability n. Industry: Up
dated Position." JOM 13 10 pp 476-478. October 1971.
2. Strasser. A.L. "Occupational Health ami Safely."
Family Practice. VV.B Saunders Company. Philadel
phia. 1973.
3. Pell. S and C.A. D’Alonzo. "A Five-Year Mortality
Study of Alcoholics." JOM 15.2 pp. 120-125. February
1973.
4. Morton. W.E "Are Medical Ethical Practices
Sufficient in Industrial Medicine?" |OM 15.11 pp.
860-861. November 1973.
ADDITIONAL REFERENCES
1. Strasser. A L. "Low Back Pam in Industry. A Posi
tion Paper." JOM 11:4 pp. 161-169. April 1969.
2. Strasser A.L. "The Foreman: At the Job Health and
Safety Firing Line." The International |ourna! of oc
cupational Health and Safety 43:3 pp. 25-26. May/June
1974
3. Strasser. A.L. "How the Occupational Physician
Works with the Safety Professional.” The International
Journal of Occupational Health and Safety pp. 32-34.
May/Apri! 1975.
4. Strasser. A.L. "Put the Once-Sick or Injured
Worker Back ci the Job." The International Journal of
Occupational Health and Safety 43:2 pp. 13-19
March/April 1974
5. The following -eries of articles by A L. Strasser.
M.D. published m Th’ Bulletin of the Monroe Count}
Medical Society.
‘‘Acute Myocardial lnt..rclion. ??? Return to Work
Date." 30 6 pp. 202-213 June 1972.
■Alcoholism." 30.4 pp. 138-139 April 1973.
Are Federal Guidelines Needed?" 30:1 Januurv
1673.
"Chronic illness." 30:11 pp. 494-495 November
1972.
"HMO s First Returns." 32:9 pp. 351-352 Septum
her 1974
"Industry’s Role in CUIms Control" 30:7 pp
246-247 |uly 1972.
"Medical Absenleeism." 30:4 p. 147 April 1972.
"Minor Illnesses." 30.5 pp 170-171 May 1972.
I r.MONVM A N A CEMhA 7
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•Neurological Disorders." 31 3 pp. 98-99 March
1973.
"Surgical Sick Leaves." 30 9 pp. 412-413 Septem
ber 1972.
"Pregnancy—Is it a Disability?" 30:10 pp. 54-55
October 1972.
"Whet We Can Learn From—"The Energy Crisis "
32:2 pp. 51-52 February 1974.
"Psychiatric Illnesses." 30.12 pp. 534-535 Decem
ber 1972.
"The Work Syndrome." 31:5 pp. 181-182 May 1973.
“Small Industry " 30:2 pp. 52-53 February 1973.
"Workmen’s Compensation." 31:9 pp. 394-396
September 1973.
i
PMOWMANAGEMENT
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WHEN WORKERS FLY
As it has evolviul. the human body functions
well al the bottom of an ocean of mixed
gases held and compressed ‘oward the earth
by gravity. This gaseous atmosphere sur
rounds the earth and exerts pressure upon
it. As atmosphi’ric jiressure dt^creases at up
per altitudes .Plained by aerial flight,
changes occur in the body’s physiological
processes. I will discuss briefly some of the
physical characteristics of the earth's at
mosphere and human physiological pro
cesses related to them.
4
PROBLEMS OF FLIGHT
PHYSIOLOGY
C. Craig Wright, M.D.
I have? borrowed freely from the manuais
and other publications listed as reference
documents. I have, in many cases, rounded
the values presented by the graphs, charts
and tables they contain. Since several of
these sources present similar but slightly
different data. I have not made specific at
tribution in my text. In no sense, then, is this
presentation my creation. If the information
given is helpful, all credit is due those who
performed and reported the basic research.
To be more easily understood. I shall be
retrogressive in my use of units expressed
in degrees Fahrenheit, feet, pounds per
square inch, and miles per hour instead c '
the more rational metric units. As an admis
sion of my recidivism, some values will also
be expressed in metric units in parenthesis.
Exclusive of water vapor in various forms,
salt particles, dust and the complex
microgarbage created by natural forces and
civilization, earth's atmosphere contains by
volume 78% nitrogen. 21% oxygen. 0.03%
carbon dioxide, and 0.97% other gases. The
three named gases are those that interest us
physiologically. Due to the mixing action of
thermal currents and other weather factors,
these percentages hold constant ir.io the
high stratosphere. The atmosphere we are
concerned with is divided into the tro
posphere extending upward from the
earth's sin face to an altitude which may varv
from 28.000 to 55.000 feet, a narrow inter
mediate tropopause layer which usually is
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perature of -67°F (-55°C).
not wider than 5.000 feel and the
stratosphere which continues outward from
the edge of ‘he tropopause to approximately
250.000 feet.
In the troposphere and tropopause, tem
perature decreases at a rather constant rate
with increases in altitude. While local air
masses and geography influence the tem
perature lapse rate, it can be generally stated
that for every 1.000 feet increase in altitude
there is a temperature loss of 3-4°F (2°C).
Thus the following overage ambient tem
peratures can be expected at these altitudes:
The trophosphere exists from the earth s
surface to an average height of 35.000 feet
and is characterized by a varying moisture
content, most of our weather phenomena,
turbulent air. a nearly constant rate of tem
perature decrease with altitude, and prevail
ing west to east winds. The troposphere con
tains within it roughly 75% of the total num
ber of gas molecules which make up the
earth's atmosphere.
Altitude
Sea Levtd
5.000 ft.
10,000 fl.
15.000 ft.
20.000 ft.
25.000 ft.
30.000 ft.
35.000 ft.
The tropopause is the narrow transition
.•one between the troposphere and the
stratosphere and has some of the charac
teristics of each. Its lower border is higher
above the earth in summer than it is in
winter and higher al the equator than over
the poles. The stratosphere is characterized
by an almost total lack of moisture and
weather phenomena, temperatures which
are nearly conslanl at -67°F. and high
velocity west to east winds often called jet
streams. Similar high speed winds flowing
roughly from west Io east are also found in
’he upper tropepause.
Temperature
59°F 15°C
50C
41°F
23°F -5°C
5°F -15°C
-12oF -25°C
-30°F -34°C
-4ft°F -44°C
-67°F -55°C
Pressure also decreases with altitude but
logarithmically rather than arithmetically as
does temperature. Sea level pressure is
usually considered to be 14.7 pounds per
square inch or. in units which will be more
useful to us. 760 millimeters of mercury. At
approximately every 53.000-foot increase in
altitude, the decimal point in the pressure
valve moves left one digit.
From a physiological standpoint, it’s of little
importance: but as a matter of interest, the
speed of sound through air. being directly
proportional to the square root of the ab
solute temperature, decreases from 760
miles per hour at the* United Stales Standard
Atmosphere Sea Level temperature of 59°F
(15°C) to 662 miles per hour constant tem-
Altitude
Pressure
Sea Level
53.000 ft.
106.000 ft.
760 mm Hg
76 mm Hg
7 mm Hg
A more useful table showing this altitude pressure relationship is given below:
Altitude
Pressure
Ratio
Sea Level
5.000 fl.
10.000 ft.
15.000 fl.
18.000 ft.
20.000 ft.
25.000 ft
27.500 fl.
30.000 ft.
33.700 fl.
35,000 ft.
40.000 fl.
760 mm Hg 14.7 psi
633 mm Hg 12.1 psi
522 mm Hg 10.1 psi
429 mm Hg 8.3 psi
380 mm Hg 7.3 psi
350 mm Hg 6.7 psi
282 mm Hg 5.5 psi
252 mm Hg 4.9 psi
226 mm Hg 4.4 psi
190 mm Hg 3.8 psi
179 mm Hg 3.5 psi
141 mm Hg 2.7 psi
1 atmosphere
1/2 atmosphere
1/3 atmosphere
1/4 atmosphere
WORKERS H '
1
Quantities of gas at various altitudes ex
pressed in percentages of the atmosphere
have little significance, for percentage repre
sents the volume of a gas and not its molecu
lar concentration. Since molecular con
centration determines the availability of the
gas to the body, the actual concentration of
any gas can be expri'ssed better in terms of
its partial pressure.
A quantity of gas mixed with other gases ex
erts the same pressure that it would if the
other gases were not present The total pres
sure of .1 mixture of gases is the sum of the
pari'dl pressure of the individual gases com
prising the mixture Although water vapor is
not a true gas. it can be considered as such in
stating the total pressure—partial pressure
relationship ’
moist air in the formula
li = pCH +
+ P^'^2 + PH2O
where B is the total barometric pressure and
pOo. pN2. pC()2 «ind PH2O are the partial
pressures of oxygen, nitrogen, carbon diox
ide and water vapor respectively. Al normal
body temperature of 98 6'F (37°C) the par
tial pressure of water vapor is 47 mm Hg.
As previously slated, drv atmospheric air
contains roughly 21% oxygen. When we
multiply the sea level total pressure of 760
mm Hg by this percentage, we show sea
level oxvgen partial pressure to be* 160 mm
Hg.
Gas
Partial
Pressure
Nitrogen
593 rnm Hg
Oxygen
160 mm Hg
Other gases
7 mm Hg
Total atmosphere 760 mm Hg
Per Cent of
Atmosphere
78%
21%
1%
100%
From the physiological standpoint it is the
partial pressure of each gas that governs its
effect in the body, not the percentage of the
gas in the total mixture.
During respiration the lung may be thought
of as a ihin diffusion membrane across
which oxygen and carbon dioxide enter and
whes nrjkKi Rs rr>
leave the blood. The nitrogen previously
mentioned does not cross the lung
membrane in any appreciable amount so
long as its partial pressure remains
u: changed. This will he discussed later
under dysbarisms. All gases lend to mov e
from high to low pressure areas and in so
doing are able to pass through thin
membranes. The blood entering the lung is
relatively poor in oxygen (therefore low ox
ygen partial pressure) and rich in carbon
dioxide (high carbon dioxide partial pres
sure). Since the inspired air has a high r.xy
gen pressure relative Io the blood, oxygen
crosses the lung and enters the blood. The
reverse situation causes carbon dioxide to
pass into the gas mixture in the lung where
it is subsequently exhaled.
The rate of respiration is normally regulated
by small sensing organs in the brain which
respond to carbon dioxide partial pressme
in the circulating blood. If the carbon diox
ide partial pressure is higher than normal,
the respiratory rate and volume are in
creased. This causes more carbon dioxide to
be lost in the exhaled gas mixture If the car
bon dioxide partial pressure is lower than
normal in the blood, the rate of breathing is
slowed io allow' CO2 to build up to normal
level.
.A second regulatory system includes small
receptors located in the large arteries close
to the heart and sensitive to oxygen partial
pressure. If the body needs more oxygen
than that supplied by the carbon dioxitie
sensitive system, this back-up system car.
and does establish a new rate and volume of
lung ventilation. The body thus defends the
partial pressure of oxygen in the blood. If
the partial pressure of oxygen is adequate
under the carbon dioxide regulating system,
well and good: if not. the oxygen sensitive
system assumes control.
This is an appropriate lime to comment on
hyperventilation which is one of the most
common physiological disturbances ob
served in individuals in flight. Hyperventila
tion is defined as an over ventilation of the
lung with resulting loss of an excessive
amount of carbon dioxide from the body.
loe
f
\
i
f
i-
____
This over ventilation is due to breathing too
rapidly, too deeply or a combination of both
and is usually secondary to (or caused bv)
fear, claustrophobia, or some other stress
which produces anxiety or apprehension.
The loss of excessive carbon dioxide pro
duces a respiratory alkalosis which may give
symptoms of light headedness. dizziness,
tingling of the fingers and toes, increased
sensation of body heat, blurring of vision,
perspiration, nausea, tachycardia, muscle
spasm, and eventual loss of consciousness.
Symptoms may be relieved by voluntarily
decreasing the rate and depth of respiration
to permit the body to reestablish a normal
carbon dioxide level in the blood. In ex
treme cases, rebreathing from a paper bag
will speed up the return to normal through
the carbon dioxide present in the previously
expired air.
Atmospheric air which is drawn through the
nasal passages and trachea into the lungs
becomes saturated with water vapor which,
at normal body temperature of 37°C. has a
partial pressure of 47 mm Hg.
In addition, the usual partial pressure of car
bon dioxide in lung air will be in the range
of 35-40 mm Hg. As the total pressure of the
inhaled gas mixture decreases at increasing
altitudes, these two gases occupy a greater
percentage of the total lung volume and act
to diminish the available oxygen partial
pressure. The higher the altitude, the greater
101
the influence produced by this water vapor
and carbon dioxide withi ! the lung. 'I he net
result of these factors is that the sea level at
mosphere oxygen partial pressure of 160
mm Hg is reduced to an alveolar oxygen
partial pressure just slightly in excess of 100
mm Hg. In the normal body this alveolar
pO2 of 100 mm Hg will produce an arterial
blood oxygen saturation in the range
95-97% .
In moving from the alveoli into the blood,
oxygen does not stay in simple solution. If
this were the case, only a relatively small
amount of oxygen could diffuse before the
oxygen partial pressures on the two sides of
the lung membrane equalized. Each red
blood cell contains a complex iron and pro
tein pigment, hemoglobin. Hemoglobin has
a strong affinity for oxygen and removes it
from simple solution through the formation
of a strong chemical union creating oxy
hemoglobin: this reversible chemical union
lowers the pO2 in the blood, permitting
more and more oxygen to diffuse across the
lung membrane. Thus a large volume of
oxygen can be transferred from the inhaled
air to the blood with only a small pressure
differential. Hemoglobin has a relatively
high affinity for oxygen at high partial pres
sures. as normally exist in the lungs, and a
relatively lbw affinity at lower partial pres
sures as are found in the tissues. This favors
a rapid loading of the blood with oxygen in
the lungs and a rapid unloading in the
tissues.
WHEN WORKERS FEY
''Fi.s, ficorHiv r i--.
Sf‘
- -FO'COI.
Re'S
d'
Figure 1
hX?
% o2
SATURATION-^h" ?6
6
10
15
20
30
40
50
60
70
80
85
90
94
96
98
2'«l
LI
30
w
40
pOj
Hg
pH ^4
pH
7^
1.7
30
44
65
87
10 7
14 2
17 5
20 9
24 7
28 7
36.3
41 1
48 7
59 5
69.7
89 8
21
38
55
82
10 9
13 4
179
22 0
26 3
31 1
36 1
45 7
51.7
614
75 0
87 7
1130
26
46
68
10 5
13 5
16 5
22 1
27 1
32 3
382
44 3
56 2
63 6
77 2
92 I
108 0
139 0
ioo
no
no
130
Oxygen Dissociation Curves for Human Blood
i
As shown by the oxygen dissociation curve,
the uptake and release cf oxygen by
hemoglobin is not a simple matter of pres
sure differentials. Notice that the right side
of the curve is nearly flat. For rather large
increases in oxygen partial pressure above
65 mm Hg. the blood oxygen saturation in
creases only slightly. This is the situation at
the lung membrane and explains why the
normal person is nearly as well oxygenated
at 10 000 feet (90% saturation) as at sea level
(97% saturation) although the total pressure
drops from 760 mm Hg to 522 mm Hg and
the alveolar oxygen partial pressure drops
from 100 mm Hg to 65 mm Hg.
Or. the left side, however, the oxygen dis
sociation curve drops sharply. This indicates
that for small additional decreases in oxygen
partial pressures, such as exist between the
blood and the tissues, large volumes of oxy
gen are released by the oxyhemoglobin and
are available for absorption and use by the
body tissue cells.
WHEV WORM RS H.1
Altitude
Alveolar Oxygen
Partial Pressure
Sea Level
5,000 ft.
10.000 ft.
15.000 it.
20,000 ft.
25.000 ft.
30.000 ft.
35 000 ft.
40,000 ft.
100 mm Hg
82 mm Hg
65 mm Hg
60 mm Hg
45 mm Hg
35 mm Hg
24 mm Hg
14 mm Hg
8 mm Hg
Blood Oxygen
Saturation
97%
95%
9G%
87%
80%
75%
47%
25%
15%
At sea level the alveolar oxygen partial pres
sure of 100 mm Hg normally produces a
blood oxygen saturation of 95-97%. At
10.000 feet, breathing air. the alveolar oxy
gen partial of 65 mm Hg produces a blood
oxygen saturation of 90% which is usually
considered the lowest saturation percentage
compatible with normal physiological func
tions. No flights above 10.000 feet should be
made without supplementary oxygen or
cabin pressurization.
102
i
I
The breathing of pure oxygen al 34.000 feet
produces the* same alveolar pO2 as does
breathing air al sea level. Breathing pun*
oxygen at 40.000 feet is equivalent to
breathing air at 10.GOO feel. As shown in the
oxygen dissociation curve, the oxygen carry
ing capacity of the hemoglobin is very sensi
tive to changes in pH of the blood away from
the usual pH of 7.4.
are dm* to insufficient oxygen part ed pres
sure in the alveoli. This type of physiological
embarrassment is called Hypoxic Hypoxia
and can be corrected either by compressing
the gas mixture prior to inspiration (through
cabin pressurization) or through enriching
the inhaled gas by adding oxygen io it. Most
oxygen masks make use of this lath r ap
proach
There are four conditions, corresponding to
the four phases of respiration, which must
be satisfied if hypoxia is to be prevented.
Adequate oxygen partial pressure must be
available for diffusion to occur across the
lung membrane. The blood must contain
sufficient hemoglobin to chemically unite
with the oxygen for transport The circula
tion system must he able to carry the
chemically bound oxygen to the tissues.
Finally, the ‘issue cells must be capable of
absorbing and using the oxygen made
available to them.
The other three conditions involving avadable hemoglobin, adequate blood circulation,
and ‘issue cells capable of using oxygen
must be satisfied if Hypoxia is Io be pre
vented Anemic Hypoxia. Stagnant Hypox
ia. and Histotoxic Hypoxia are. howevi*r.
beyond the scope of this presentation..
In flight, most cases of hypoxia which occur
The symptoms and effects of Hypox«a de
pend upon the degree to which it is present
and upon the individual responses of the
Hypoxic individual. The table below sum
marizes the most common symptoms of Hy
poxia by time of exposure to various
altitudes:
r.
£
SYMPTOMS OF HYPOXIA
Altitude
Time of
Exposure
10.000 to
14,000 feet
Hours
15.000 to
18.000 feel
30
minutes
impairment of judgment and vision,
high self-confidence, euphoria
disregard for sensory perceptions,
poor coordination, sleepiness,
dizziness, personality changes as
<f intoxicated, cyanosis.
20.000 to
35.000 feet
5
minutes
Same symptoms as 15,000 to 18.000
feet only more pronounced with
eventual unconsciousness.
35.000 to
40.000 feet
15 to 45
seconds
Immediate unconsciousness
(with little or<u) warring!)
103
Symptoms
Headache, fatigue, listlessness,
noa-specific deterioration of
physical and mental performance
IVOHKf.R*; H 5
i
I
!
The most outstanding characteristic feature
of hypoxia is its gradual and insidious onset.
The hypoxic individual commonly believes
that things are getting progressively better as
he nears total decompensation. While not all
of the symptoms mentioned occur in each
individual, any given person will develop
the same symptoms and in the same order
each time he becomes hypoxic. For this
reason, any individual, having once ex
perienced hypoxia under careful supervi
sion. is better prepared to recognize his con
dition if hypoxia occurs again. Usually, as
observed by an oxygenated observer, the hy
poxic individual will manifest a decrease in
mental and physical activity, a loss in judg
ment and coordination, and a clouding of
thought and memory. He may show tremors
of hands and fingers, and personality
changes similar to those of intoxication. The
hypoxic individual may be completely
unaware of the above changes, particularly
if his hypoxia is rapidly progressing. If hy
poxia continues, unconsciousness, convul
sions. and death may ensue.
Not al! individuals are equally susceptible to
the development of hypoxia. Each person's
susceptibility may vary from day to day de
pending upon numerous factors. Fatigue, in
fection. overindulpence in alcohol and
tobacco, fever, low blood sugar following in
adequate food intake, emotional distur
bances. certain drugs, poor physical condi
tion, and many other factors may increase
an individual's susceptibility.
One aspect of hypoxia requires further dis
cussion. Although the hypoxic individual
may remain conscious for a longer period,
he has only a limited time in which he is
capable of performing useful acts. The time
of useful consciousness al any altitude is the
maximum length of time the exposed in
dividual has to perform the useful tasks
i.ecessary for his survival, such as the im
mediate donning of an oxygen mask.
ttHFA WORKERS Fl *
Time of Useful Consciousness
22.000 feet
25,000 feet
28.000 feet
30,000 feet
35,000 feet
40,000 feet
65.000 feet
5 minutes
2 minutes
1 minute
45 seconds
30 seconds
18 seconds
12 seconds
The shortest times, 12 to 15 seconds, depend
upon the circulation time of the last oxygen
carrying blood from the lung to the brain.
The treatment for hypoxia is the re-estabiishment of an adequate oxygen partial pres
sure in the lung. This may be accomplished
through the use of an oxygen mask, pres
surization. or descent to a lower altitude.
Recovery from hypoxia is usually rapid, oc
curring within 15 seconds after oxygen is
administered. Transient dizziness may oc
cur during the recovery. The severely hy
poxic individual will usually have no memo
ry of having lost consciousness. Artificial
respiration has been necessary in some
cases. However, to be effective it must be
given very shortly after the cessation of
breathing. Permanent brain damage follow
ing a short period of hypoxia is extremely
rare.
Although recovery is rapid following the ad
ministration of oxygen, a word of caution is
necessary. The individual recovering from a
moderate to severe hypoxia incident is
usually qrile fatigued and may suffer a
measurable deficiency in mental and physi
cal performance for hours.
Normally there is gas present in various
body cavities including the stomach, in
testine, middle ears and nasal sinuses. If.
under conditions of low total pressure, this
trapped gas expands and is unable to pass
out of the containing cavity, severe pain may
result. The following graph presents the ex-
104
pansion ratio of this trapped gas at various
altitudes-
Altitude
Approximate
Volume Ratio
S'*a level
10.000 feet
18.000 feet
20.000 feet
25.000 feet
30.000 feet
35.000 feet
40.000 feet
50.000 feet
1.0
1.5
2.0
2.4
3.0
4.0
5.4
76
17.0
In addition Io these trapped gases, there is a
considerable volume of gas. primarily
nitrogen, dissolved in the blood and other
body fluids. When the ambient pressure
falls, these gases tend Io come out of solution
with the formation of gas bubbles. This
phenomenon is similar to the bubble forma
tion in carbonated beverages when the bot
tle cap is removed, lowering the internal bot
tle pressure. When these bubbles form in
the body, severe pain may result, as well as
bizarre neurological symptoms. Pain caused
by bubble formation in and around joints is
called the "bends." The same bubble forma
tion in the lungs causes a burning sub-ster
nal discomfort called the “chokes." Th”
neurological symptoms including skin itch
ing or mottling, tremors, paralysis, or con
vulsions result from bubble formation in
nerve or brain tissue, or from bubbles car
ried to these tissui’s by the circulation. All of
these conditions may cause? generalized
body collapse with the low blood pressure
and rapid pulse of clinical shock. Symptoms
referable to trapped gas expansion and gas
bubble evolution an? crlled dysbarisms.
/
i
While the symptoms of trapped gas expan
sion develop fairly rapidly, the symptoms
due to bubble formation do not occur for a
considerabl'.? period of tim \ At 35.000 Io
40.000 fed it takes approximately twenty
minutes for the average individual to
develop severe or incapacitating symptoms.
Evolved bubble symptoms (bends, chokes)
rarely occur below 20.000 feel. I heir fre
quency and severity art? dependent upon the
rati? of pressure loss, the total ambient pres-
I
sure, the’ elapsed lime at altitude, and the
ambient temperature.
Exercise increases both the frequency and
severity of symptoms. Due to the high
solubility of nitrogen in body fat, obese in
dividuals are considerably more prone to
develop bends than the average person. Both
the prevention and the treatment of dysbar
isms consist of descending to a lower
altitude (higher total pressi-e) as rapidly as
possible.
Some persons have trouble clearing theirj
ears following flight, particularly flights
made in unpressurized aircraft. Almost
everyone? who flies regularly will encounter
this problem at some lime or other.
The ear canal is constantly at the same pres
sure as the atmosphere surrounding the
head. The middle ear. containing the three
bones, is a small air-filled cavity situated
within the bone of the skull, separated from
the ear canal by the tympanic membrane
and connected Io the nasal cavity by the
Eustachian tube. As ascent to altitude is
made, the ambient pressure decreases, thus
lowering pressure in the ear canal. The in
itial result is that the pressure in the middle
ear exceeds the canal pressure and the
eardrum bulges outward somewhat. In the
middle ear. however, only a slight excess of
pressure opens the Eusht ;hian tube and the
gas passes outward, equalizing the pressure
on the two sides of the eardrum. The in
dividual may be aware of this pressure
change only through recurrent mild sensa
tions of fullness in his ears. It is rather ran?
for ear pain Io develop during ascent since
middle ear ove»-pressure is so easily re
lieved.
During descent, the reverse occurs. As the
surrounding air pressure increases, a rela
tive negative pressure? or vacuum develops
within the middle ear and the eardrum
bulges inward. This condition is more
difficult to relieve since the problem now is
Io introduce air back up the Eustachian tube?
to relieve the vacuum.
For a moment imagine the Eustachian lube
WHES WORKERS H
105
\
\
!
i
as a soggy, limp, drinking straw. It is fairly
easy t blow air out through the straw but at
tempt: at sucking air in through it occa
sionally collapse the straw completely. The
more gentle the attempt to suck the air in. the
more successful it will be. so long as the
walls of the straw are not completely in ap
position.
If you have an upper respiratory infection,
the tissue around the nasal end of the
Eustachian tube will probably l.e thickent d.
and you can expect to have more ear aouble
during descent than you normally would.
When flying with a cold, you shouid
routinely use a vasoconstricling agent before
the letdown is started.
During descent the individual is usually
aware of this negative pressure in the mid
dle ear by a sense of eardrum tension, a sig
nificant loss in ability to hear, and a vague
discomfort turning into an actual pain if the
condition worsens. Chewing, yawning, and
swallowing will cause small muscles around
the nasal end of the Eustachian tube to con
tract. holding open the mouth of the lube.
These motions are usually followed by
reinflation of the middle ear. giving com
plete relief of symptoms. If these actions are
not followed by reinflation. additional
measures are necessary.
Occasionally, you may notice the same con
dition involving your nasal sinuses. 'I’tiese
sinuses, like the middle ear. are air filled
cavities which vent into the nasal cavity. The
rein flat ion methods previously described
are also effective in relieving any partial
vacuum which may develop in th'‘se
sinuses.
The most efficient method of reinflating
your middle ear calls for you to squeeze
your nostrils together between your thumb
and forefinger. You should then imagine
that the upper portion of your nose is a
balloon. Holding your nostrils to form an
air-tight seal, you should SLOWLY AND
GENTLY build up pressure in your nose as
though you were blowing up the balloon. At
some point during this procedure you
should hear or feel air enter your middle
ear. If the vacuum has been present for only
a short period you will immediately notice a
marked improvement in your ability to hear,
and a disappearance of the sense of fullness
and discomfort.
If this balloon inflation maneuver is unsuc
cessful. you should use nosedrops, an in
haler. or nasal spray. After waiting a short
time for constriction of the tissue around the
mouth of the Eustachian tube, repeat the
balloon blowing maneuver. You will find it
easier to keep your ears pressurized during
descent if you GENTLY inflate your nose
balloon every minute or so during letdown.
If you have frequent ear trouble on descent
you should routinely use one of the shrink
ing preparations mentioned above. 15
minutes before the descent is started.
WHfS IVORM RS H >
/
Toothache brought about by decreased
barometric pressure at high altitudes seldom
occurs in flight. Nevertheless, persons who
have defective fillings, caries, and periapical
abscess may be particularly predisposed ’o
this discomfort. Occasionally, aerodontalgia
may have a basis in pain referred from max
illary barosinusitis.
REFERENCES
1 Physiological Training Air Force Pamphlet 160-5.
Department of the Air Force. 1976.
2. Flight Surgeon’s Guide. Air Force Pamphlet
161-18. Department of the Air Force. 1968.
3 Medical Factors in Flight Aircraft Division.
United States Steel Corporation. Pittsburgh. Pennsyl
vania 1965.
4. Medical Aspects of Business Aviation. A Joint
Committee Report of the Aerospace Medical Associ
ation and the Industrial Medical Association JOM
28 336 352. 1964: also Aerospace Medicine 8:783-793.
1964.
f>. "Medic.al Criteria for Passenger Fixing " Ar"h En
viron Health 2:124-138. VI61
6. Medical Aspects of High Altitude Flight PanAmerican World Airwavs. JFK International Ai.pnit
New York. N Y 1959.
7. instructors Manual for Physiological Training Air
Force Manual 52-13 Department of the Air Force. 1953
8 I’hvsio'iogv of Flight. Air Force Manual 160-30.
1953
9 Wright CC ' Factors'Influencing Air Transporta
tion of Sick and Injured " |OM 12 732-736 1962
KMi
Travel by air carriers has become one of lhe
safest, most efficient ways to travel for the
worker and his family, be he white or hint?
collar worker. Deaths during air travel, not
due to accidents, average world-wide only
0.4 passengers per million passengers car
ried.
COMMERCIAL AIR LINES
Ludwig G. Lederer, M.D., Ph.D.
■
I
i
It is estimated that 7()o'j of a physician s pa
tients travel by air. Fitness for air travel can
easily be assessed by the physician in sim
ple terms. If your patient can climb one
flight of stairs without resting, or walk one
city block, in all probability, he can safety
take a trip by air without difficulty. Many
patients can travel with little or no problems
if (hey are properly assessed by the physi
cian. Table 1 shows the Civil Aeronautics
Board criteria of lay and professional accep
tance of certain disabilities.
On American Airlines, we now carry 25
million passengers per year. Each day we
dispatch 1.000 flights. A passenger with a
clinical condition which was stable at (he
beginning of'a flight may deti?riorate as the
flight progresses. These instances are few
and far between, necessitating an
unscheduled landing for medical reasons.
Note we do not call these “emergency” land
ings; emergency landings are only those in
volving an unsafe condition of an aircraft or
its components. We average 50 such
unscheduled landings per year. In the? past
few years, physicians traveling as passen
gers. who have been called upon to act as
Good Samaritans to help our flight atten
dants and crew, have requested more medi
cal equipment on board for professional
use. The goveinmental agencies, the C.A.B..
and the Federal Aviation Administration are
aware of these requests. We do carry on
board first aid equipment and some drugs,
but these are in the category of a “home
medicine cabinet."
WHEN WCIRKEKS El >
107
!
I
I
LAY
ACCEPTANCE
I
Stable. .Ambulatory
X
1
Stable. Non-Ambulatory
Non-Stable. Ambulatory
X
X
J
PROFESSIONAL
ACCEPTANCE
X
X
Nor.-Stable. Non-Ambulatory
EXAMPLE
4-6 Weeks Post
Myocardial Infarction
Paraplegic
Infectious Mono Viral
Hepatitis
Advanced Emphysema
Table 1
Civil Aeronautics Board criteria of lay and professional acceptance of certain disabilities.
!
I
and closed cardiac massage. The leaching of
the Heimlich Maneuver for the "cafe coron
ary" victim has paid good dividends in our
airline.
The A.irline Medical Directors in the U.S.
have repeatedly voted not Io carry "doctor
type’ medications. In this day of malpractice
dilemmas, it is easy to see why an
ophthalmologist being the only physician on
board would be reluctant to use cardiac or
pulmonary emergency drugs. Instead, the
trend is to make sure that all airlines ade
quately train and give refresher courses to
the crew and flight attendants in car
diopulmonary resuscitation techniques in
cluding mouth-to-mouth, mouth-to-nose.
Recently the FA A has recognized the needs
and problems of the disabled. Table 2 shows
the number of persons handicapped by
various diseases and conditions. Table 3
shows the geographic distribution of handi
capped persons in various regions of the
United States.
i
!
■
HANDICAPS OF WORK FORCE AGE AMERICANS
No. of People
Handicap
5.400.000
3.500.000
250.000
2.000.000
250.000
2.000.000
700.000
450.000
200.000
Paralysis (Muscular-Skeletal)
Mentally retarded
Mentally restored
Hearing loss (not total)
Total deafness
Epilepsy
Blindness
Kidney failure
Amputee
Table 2
Statistical source: 1970 U.S. Census, the President s Committee on Employment of the Handicapped.
National Easter Seals and Lawrence Berkley Laboratory
IVORKF R’i F l '
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GEOGRAPHIC DISTRIBUTION OF
THE HANDICAPPED
In Labor
Force
Region
Not in Labor
Force
(able to work)
Total
Handicapped
389.988
796.163
778.201
313.536
76.452
2. (N J.. N.Y.. Canal Zone. P.R.. V.l.)
622.733
173.430
3. (Va.. W'. Va.. D C.. Md.. Del.. Pa.)
4. (Ala.. Miss., Fla.. Ga.. S.C.. N.C.. Ky.. Tenn.)
600.497
177,704
917.775
288.036
1.205.811
1.212.603
363.876
1.576.479
576.646
174.541
751.187
324.176
86.871
411.047
1. (R.L, Conn.. Mass.,. ’ H.. VI.. Maine)
5. (III.. Ind.. Mich.. Minn.. Ohio. Wis.)
6. (La.. Ark.. Okla.. Tex.. N.M.)
7. (Iowa. Kansas. Mo.. Neb.)
8. (Mont.. N.D.. S.D.. Colo.. Wyo.. Utah)
158.061
44.241
202.302
9. (Ariz.. Nev.. Calif.. Hawaii)
661.770
216.551
878.32 i
10. (Alaska. Wash.. Ore.. Idaho)
207.673
67.459
275.132
5.565,470
1.669.161
7.264.(531
TOTALS
Table 3
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Statistical source: 1970 U.S, Census, the President’s Committee on Employment of the Handicapped.
National Easter Seals and Lawrence Berkley Laboratory.
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It has only been in the past two years that we
have developed equipment and care for the
passenger who needs oxygen "all the way.
This embrace* primarily the area of
emphysema. All of these cases in our airline
are assessed for travel by having a consulta
tion often by telephone between the pa
tient’s personal physician and one of our
full-time flight surgeons. We use only our
own oxygen equipment which is solid stale.
However, the rate of flow is often a problem
in that the treating physician overempha
sizes the need. In many instances, if we
mention to the physician what the physical
capability of the passenger is. namely,
climbing a flight of stairs or walking one city
block, no added oxygen is really needed. For
passengers who cannot be handled by us.
air ambulance service is now available.
There are two other areas of concern in air
travel, one is that of smoking or non-smok
ing in passenger and crew areas, and the
other is the over-indulgence of alcohol
which is a real problem. Let us take the
smoking issue first. The non-smokers.
109
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especially those who have given up the habit
and become converts to a new way of lift;,
are most vociferous in their demands for an
all "no-smoking” rule. We find these people
are becoming the majority, and we are grad
ually reducing the "smoking area in our
aircraft seating configuration. When there i?
a transgression, the arguments become
violent and if aided and abetted by alcohol
intake, xve have had instances occur of
assault and battery.
We have our own problems in this area wi’n
reference to cabin and cockpit crew and
smoking habits. Medically, we have told our
people that "smoking (cigarettes) is bad for
their heahh " We have some who will net
heed our warning. I lowever. there is no e.rea
on the airciaft except buffet areas when'
with curtains drawn, a flight attendant can
"sneak" a smoke. The lavatories are "off
limits.” and so is the cockpit area where we
have a rule that there .will be no cigarette
smoking by flight attendants without the ex
pressed approval of the captain. The reason
for that ruling was the occurrence of unapHUES WORKf.RS H '»
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proved cigarette smoking by flight atten
dants during the last half hour of descent in
transcontinental flights. This is a period dur
ing which, on the recommendation of the
Medical Department we ask our cockpit
crew to go on 100% oxygen voluntarily to
overcome the? subclinical hypoxia induced
by a four hour plus period of operating at a
cabin altitude of 7.500 feet.
We have not solved the problem of cigarette
smoking in our cockpit crew members, and
there is much activity going on in this area,
but it is a complex subject. However,
because we use limed velocitv of pulmonary
function as part of our Pilot Health Mainte
nance Program, we have had success in
stopping cigarette smoking in those in
dividuals who are showing a decrement in
pulmonary function. At one pilot base, we
have stopped cigarette smoking in 30% of
our cockpit crews!
There are other factors that affect the com
fort and well-being of the traveling worker.
One of these is the health habits during long
periods of air travel. A good rule to follow is
to give the traveler adequate time to ac
complish his journey. Adequate time to get
to the airport (overseas flights require a one
hour pre-flight check in) is important. Carry
ing of heavy baggage by the elderly over
long distances is to be avoided. We lost more
passengers from heart attacks prior to and
after the flight than during the flights.
Comfort factors with respect Io eating and
drinking on board aircraft are important.
Overeating and overindulgence in alcoholic
beverages should be avoided. We have a
problem here with the wife accompanying
the passenger. She wants Io treat this trip as
a “night on the town" and wants to be dined
and wined accordingly.
WHEN WORKER*. Hl
Another factor to cope with in travel by air
carrier is the distinctly low humidity of the
cabin and cockpit area. Fluid balance should
be maintained by adequate fluid intake
preferably by non-alcoholic and non
diuretic beverages. We give the same advice
on fluid intake to our cabin and cockpit
crew. Of course, alcoholic beverages are for
bidden to aircraft crew members for twentyfour hours before flight time.
Also, because of the low humidity referred
to. wearers of contact lenses should have
welting solution available to use at frequent
intervals while in flight. We give the same
advice to our flight attendants who wear
contact lenses. In this same vein, passengers
who are on timed medications like insulin or
insulin-like oral medication should be sure
to have the medication available on board
and not packed in their luggage which is not
immediately available to them.
With reference to immunizations for foreign
travel, the requirements are becoming much
more liberal. As an example, smallpox re
quirements are no longer necessary for
European and Mexican travel. The ineffec
tiveness of cholera immunization is recog
nized by the World Health Organization.
Yellow Eever immunization, good for ten
years, and anti-malarial medication are still
prime requisites when traveling to infested
countries. A good anti-diarrheal medication
is a real asset because the two greatest fears
of the international air traveler are still “tra
velers' diarrhea" and the fear of flying.
In conclusion, air travel is still a very safe
way to traverse long distances for everyone,
the young and the old. the weak and the
•.trong. the healthy and the infirm.
110
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The General Motors Overseas Division
known as the Genera! Motors Overseas
Operations is headquartered in the General
j
Motors Building in New York City. It is the
responsibility of the New York and Detroit
G.M.
medical
departments
to
prepare
medically each General Motors Overseas
Operations employee as well as each accom
panying member of his or her immediate
family before proceeding on
a foreign
assignment or an extended international
business trip. Approval of an overseas
assignment or continuing thereon is con
tingent on obtaining medical clearance for
PREPARING
WORKERS FOR
INTERNATIONAL
TRAVEL
the International Service Personnel (ISP) as
well
as
for
members of the
immediate
family who accompany him. Therefore, the
medical examination
must
be completed
before the assignment or continuation
thereon is finalized. This policy is an at
tempt to reduce the possibility of medical
problems that could affect the ISP’s perfor
mance necessitating his premature return to
his home country or that could result in con
Nicholas A. Pace. M.D.
tinuing medical problems after his return.
Scheduling of the medical examinations is
done as early as possible. This allows time
for additional consultation or treatment if
necessary. The ISP medical examination is
scheduled for three or four days before his
home leave begins, allowing time for addi
tional consultation if necessary. In other
words, his home leave begins only after the
examination has been completed.
The Personnel Department of the Overseas
Operations has advised all of our overseas
plants that the International Service Person
nel as well as their immediate families are
required to maintain their inoculations and
vaccinations up to date. All of our overseas
plants are referred to use our Ganural Motors
Medicol Guidebook for Eondj’n Trovi’l and Ser
vice.
Any General Motors employee or member
of his immediate family who experiences an
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illness or an injury while on foreign assign
ment or on an authorized business trip is ad
vised to report this problem to the Medical
Department immediately upon returning
from the trip. The company will pay for any
diagnostic, medical, surgical, or hospital ex
penses incurred by employees and their im
mediate families as a result of an environ
mental illness contracted in the line of duty
abroad to the extent that such expenses are
not covered under our insurance program.
However, the company will not pay for any
medical expenses due to an illness other
than an environmental illness. Our defini
tion of an environ mental illness is a disease
or illness that is endemic in the foreign loca
tion and which probably would not be en
countered if the employee and his immedi
ate family had remained in his own home
country. Conversely, the non-environmental
illness is that illness for which risk of ex
posure is the same as that incurred while
worxing in one's own home country. Should
an ISP or member of his immediate family
develop a serious medical problem at the
assignment point, which in the opinion of
the local management requires a higher
quality of care than is available locally, the
company will assume the expense of mov
ing the patient to a location where proper
medical or surgical care can be obtained
whether the illness is classified environ
mental or non-environmental.
Prior to the time of the examination, the Per
sonnel Department provides the employee
and the family members with the following:
date and time of examination, letter of in
structions for medical examination, a medi
cal questionnaire, also a stool specimen kit
with its instructions. On the day of the ex
amin ion the family arrives in a fasting
state to the medical department with their
completed questionnaire and stool speci
men. The nurse interviewer reviews the pa
tient's home leave itinerary containing ad
dresses and phone numbers so that the pa
tient can he reached if necessary for further
medical follow-up. The nurse discusses
family adjustment to environment housing,
food, sanitation and so forth, and' records
this on a confidential sheet. Special health
problems such as availability of medical
facilities, hospitals, physicians, and raedicaWORKERS »/.>
tions are also reviewed by the nurse. The
nurse also reviews all medical systems and
questions the use of drugs, tobacco, and
alcohol. She has been instructed to under
line and alert the examining physician io
any medical problem areas, and in this way
the physician can concentrate on these prob
lem areas du. ing the course of the examine
tion. The immunization schedule is then
reviewed and the necessary immunizations
are recorded and scheduled on a special im
munization schedule form. The family then
proceeds to have a standard series of
laboratory tests which include a chest X-r«y.
a resting electrocardiogram for all adu’lr
over the age of 30 and/or anyone with a
history of heart disease, a hemogram which
includes a complete blood count and routine
blood chemistries, a complete urinalysis
and a stool examination for blood, ova and
parasites.
Following ihe laboratory procedures the ex
aminee is then brought to the examining
room where the physician reviews the histo
ry form, giving special attention to the nurse
interview notes. The family is examined
thoroughly by the physician who fills out th.?
General Motors Foreign Assignment Medi
cal Examination Report. At the bottom of
this report the diagnoses are listed as well as
the recommendations for treatment or
further consultation. He then fills out a
qualification form indicating that in the
physician’s opinion the examinee is er is not
physically capable of performing the duties
of an overseas employee as well as any
medical limitation to foreign travel or
assignment that the employee may have
This form is then submitted to the Personnel
Department. Following the physical ex
amination. appointments for any necessary
referrals are scheduled. All females aiu
referred to the gynecologist for pelvic ex
amination and pap smear. The pediatrician
in turn submits a standard G.M PediatHc
form to the company clearing the children
for foreign station.
The International Service Personnel is told
to call or return to the Tnedical department
one week later for a comprehensive review
of the results of the physical examination,
laboratory procedures, and medical recom112
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snendations. In addition to this review,
either in pt!r*-'*n or on the phone, a complete
set of records are sent to the patient al his
overseas assignment. The Personnel Depart
ment is notified of the medical status of the
employee and his family.
At the end of the examination, the nurse
reviews the physician's recommendations
with the family via an exit interview. It is
during that interview that a list of travel tips
are supplied to the traveler as well as an in
ternational medical travel kit which includes
drugs and instructions for use of the medica
tions while overseas. If the family is travel
ing to a malarious area, malaria prophylactic
medication is supplied. If the worker is
going Io a tropical area, a supplementary
tropical medical kit is added to the interna
tional travel kit
Our lnternalion.il Service Personnel are ex
amined once every two years when they
return from home or from ordinary assign
ments. If they are in a hardship area, for ex
ample. an underdeveloped country, they
return home and are examined on an an
nual basis, since it is usually in these areas
that disease exposure is greater and medical
care is poorer.
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The post tr.ivel interview is performed by
the nurse on ISP s who return to home office
»:.i a trip of less than six months of interna
tional travel or assignment. The employee is
told to report Io the medical department for
an interview which would include having: 1.
a review of any illnesses or symptoms that
have occurred over the last six months. The
doctor may decide, at this point, to examine
the patient for the system involved in the ill
ness or symptoms: 2. the travel kit
replenished: 3. immunizations updated, and
•!. stool examinations if indicated. (Indica
tions for stool examination would be:
returning from an undeveloped area, a trop
ical country, or having an episode of diar
rhea during the last six months or since the
previous examinations.) 5. any other mi’dical laboratory procedures that the physician
might deem as necessary.
The schedule for preparalion of the ir.ierna-
tional traveler's immunization was devised
by our committee, in accordance with U.S.
Public Health Service schedule. We also
took into account such problems as im
munizations to satisfy local health
authorities, as well as what immunizations
should be given in order to pro' kie max
imum protection to our people. Please note
that our definition of Northern Europe in
cludes England. Scandinavia. West Ger
many. Switzerland. Belgium, and Holland.
All our International Service Personnel
while on foreign assignment throughout the
world are expected to maintain their im
munization program outlined below. If cer
tain vaccines are not available locally, every
effort is made to obtain them from other
sources including the home medical office.
We also realize that dosages are often
changed, and. therefore, the manufacturer’s
recommendations listed on the oacki.ge
should supersede any of our manual's direc
tions.
Siaallpox Initial dose—one revaccination
every three years for all international trips
except for Canada and Northern Europe. If a
person is traveling to an area where
smallpox has been reported recently, then
revaccination should only be given when
vaccination was given more than a year
earlier. Note, all revaccinations must have a
take.
Typhoid Initial series number of doses 2—
each dose is 0.5 ml subcutaneously, at least
four weeks apart. Booster, one dose 0.5 ml.
subcutaneously, to be given every three
years for all international trips except
Canada and Northern Europe. Note, all
those actively involved in travel to high risk
areas should have a booster annually. Most
typhoid strains no longer respond to ordin
ary antibiotic, therapy: therefore, immuniza
tion is important.
Tetanus toxoid The initial series for
tetanus toxoid requires three doses, each
dose being 0.5 ml., subcutaneously, at least
four weeks apart, for the first two doses, and
the third dose being given one year later A
booster is required every ten years for all in-
s
UHEV UORKCRS H
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ternational trips except Canada and North
ern Europe*. If the* patient is exposed te> a
penetrating dirty wound. Ihe immunization
will protect providing a toxoid injection is
repeate*el after exposure?. Therefore, a
booster should be’ given upon Ihe eiccurrence’ of penetrating wounds or burns as
dire’cle’d by a physician.
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Typhus The typhus immunization initial
seu ies is a number of two doses. Each dose is
erne* millilileT subcutaneemsly. The*re? is an
eiptional interval bi’tweem initial deises of
four weeks. Boosle’r eloses of typhus should
be once* a year. The use’ of typhus vaccine? is
optional It is not mandatory, because
typhus is a treatable disease: neverthe*le*ss. it
is n’commended in the pre*sene;e of elanger
of epidemic lice or lice-borne typhus. It is
not necessary in Canada or Northern
Europe* 11 should be considered for travelers
to rural or remote areas of Ethiopia. Rwan
da. Burundi. Mexico. Ecuador. Bolivia. Pe*ru.
and other mountainous areas.
Chedera Has an initial series of two doses,
the* first dose being 0 5 ml., the second dose
being 1 ml subcutaneously, at least seven
days apart. Boosters of cholera are required
(•very six months Chole’.a can be givem for
all international travel except Canada.
Northern Europe*, and Latin America.
Cholera is given mainly to meet Ihe require
ments of the country. Exceptions will be
made if there is lio e hc.lera in the area and
Ihe country Io he* visiteel does not require?
this immunization.
Polio-Sabin The initial series of polio is a
number of three* doses—the second elose al
least six weeks apart from Ihe first dost? and
the third dose being 8 to 12 months after th»*
second. A booster is requireel every four Io
five years. Polio race ine is given for all in
ternational travel except for Canada and
Northern Europe* and it is optional after the
age of 50
Influenza The U.S. Public Health Service
recommends that those’ over tne age of 50
should receive* the* flu vae.cine. All travelers
with careliac or respiratory diseases should
re’ci'ive Ihe flu vae.e ine I he flu vace'.ine is
nm x wiwki px n '
now in a single dose of 0.5 rni. sub
cutaneously and it is much less toxic an.el has
fewer reactions than the* flu vai:e:ine of vears
ago.
Yellow Fever Initial dose—one. It is valit.
for ten years beginning ten days after ihe
primary vaccin.ition. /\ booster is given ev
ery ten years mainly to meet the require
ments of Ihe count ’ to be visited. Il should
be given for all intern.ition.il travel except
Canada and all of Europe.
Plague (Follow manufacturers instruc
tions for dosage and the amount.) A booster
is given at six months interval and only m
the presence of the danger of plague or for
those traveling to remote interior areas <;f
Viet Nam and Cambodia.
BCG Vaccine This especially for chihlren.
BCG vaccine should be reviewe.! by a
pediatrician on an individual basis lor those
scheduled for an e’xlended slay in the trop
ics.
Gamma Globulin Gamma globulin should
bet given just prior to departure and every
six months in a dose of 5.0e:c for all interna
tional travelers exempt those going to Canada
anil Northern Europe*. Gamma globulin
should he givem to those? persons stationed
ove*rseas in areas other than Canada anil
Neirthern Europe’ on a six months batis. If
there' is a high incidene:e of hepatitis re
pented in any particular area, this schedule
should he* mollified so that gamma globulin
be? given every four months insti’ad of every
six months. When possible*, patients going
overseas should be given gamma globulin as
their last inoculation just two e»r three* days
prim to departure*.
The simultaneous administration of certain
vaccines, according to the U.S. Public 1 irallh
Service, is both safe and efh'ctive. This is
important for the traveler who has imminent
exposure to several infectious diseases and
limited time access to call for vaccinations
with multiple antigens According to the
U.S Public Health Service, "inactive vaccines and large attenuated viral vaccines can
he administered simultaneously at separate
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sites keeping in mind the precautions that
apply to single antigens or a combination
product. Smallpox and Yellow Fev<»r vac
cines (once thought to be unsuitable for
simultaneous administration because of
virus iroerference) can now be given at the
same time at separate sites with an effective
ness and safety equal to that following an in
dividual administration. Furthermore, since
the reactigenicity and the antigenicity of the
smallpox and yellow fever vaccines are
unaffected by the interval between inocula
tions. it is not necessary Io separate the in
jections by two to four weeks if they cannot
be given simultaneously."
Malaria prophylaxis This is advised for
employees traveling through Africa. South
west Pacific. Far East. Southeast Asia. Mid
dle East, and specific areas of South
Amer.ca The dosage schedule is as follows:
1. Chloroquine (aralene) 500 mg. weekly
beginning one week prior to departure and
six weeks following return.
2. If traveler is to remain in the malarious
area on a continuous basis, them suppressive
treatment is to be continued in excess of six
months, chloroquine is to be alternated with
pyrimetamine (daraprim) 25 mg. weekly for
three months alternating with chloroquine
for six months.
noted that most of tin; cases of malaria that
occur now are in the businessman who
foolheart(‘dly believes that he is immune to
malaria.
THE GENERAL MOTORS
INTERNATIONAL TRAVEL KIT
The traveler is given a General Motors Intel national Travel Kit. In the kit there an? vials
labelled with the various medications ar."
an instruction sheet which cautions the trav
eler to read the labels carefully and avoid
alcoho1 use with any of the medications
since alcohol with medications may cause
undersirable interreactiens which may be
severe. The traveler is also cautioned that if
symptoms persist, competent nwdical assis
tance should be sought out either through
our nearest local General Motors facility, the
American Consulate, the Internationa! As
sociation for Medical /Xssistance Io Trav
elers directory, or by calling the Company
Medical Director in New York long distance.
The kit includes medications to take care of
most common medical problems. I Ik? com
pany realizes that the cost is Irmnendou" to
send a traveler on a business trip. Should
the business traveler become? ill while over
seas. not only is it detrimental Io his health
but also io the business purpose of the trip
The medications that the International
Travel Kit includes are listed with their
doses and directions.
Precautions S.nce chloroquine can cause
serious eye problems, persons taking these
drugs should have annual eye examinations
regardless of whether any eye problems are
experienced. Ex amination is at company ex-
For those going to a tropical area, a tropical
kit is supplied in addition lo the interna
tional kit. In the tropical kit there are
medications to treat severe allergic reactions
or hives due to an insect lute, or food or drug
allergy. Then? is also medication for
prophylactic use for diarrhea prom trav
elers. Also included in the kit an* medica
tions for sunburn prevention, ilchiness.
fungus infection, protection against malaria,
water purification b.blets. sodium (.bioride
and dextrose tablets to avoid heal prostra
tion. an insect repellent and finally a snake
pnnse by an ophthalmologist during home
bite kit.
The employees' children are advised to have
individual doses of medication, per pound
not kilo. Infants should be checked by a
pediatrician; drug therapy is probably not
necessary, but they should be protected by
anti-mosquito means, i.e.. nets.
leave or locally by an ophthalmologist dur
ing the intervening years, if any eye com
plaints occur during the years of chloro
quine use. the drug should be stopped and
an ophthalmologist consulted. It should be
115
SUPPLEMENTARY ITEMS TO BUY
We also give the traveler a supplementary
list of items he should I.ike with him. The
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supplementary list includes an adequate
supply of any medications that his own
physician may have prescribed; an extra
pair of glasses and a prescription for his
glasses; a bar of soap for cleaning the skin
and preventing infection; a box of Kleenex,
one soft pack per week for toilet use; an
aerosol insect killer spray, such as Raid for
use in hotel rooms: a thermometer; a
tweezer to remove foreign bodies; a small
paJr of scissorc; a triangular bandage; a
small immersion water heater, and an
electrical ad. nter for continental outlets. In
addition to the travel kits the traveler is pro
vided with a list of medical travel lips on
how to stay well during international travel
and assignment.
We surest that the traveler drink bcdled
water which is carbonated and perhaps
even c< rry his own bottled water which now
comes n convenient quart plastic bottles. If
one uses bottled water that is purchased
locally, one should make sure that the bottle
is opened in front of the traveler and that the
bottle fizzes when it is opened. We suggest
the use of bottled water to brush the teeth.
Ice should be avoided. We also suggest that
all uncarbonated soft drinks be avoided,
since the sugar in them makes an excellent
media /or bacteria. One should check that
ihe glass he uses is clean. If one cannot boil
the water, we suggest the use of an immer
sion water heater in a cup. This inexpensive
instrument can boil a glass of water in less
than a minute. The traveler is cautioned in
the undeveloped parts of the world to avoid
m»lk. cheeses, and ice cream unless he is
certain that it has been made safe by
pasteurization. If milk is required, one can
use bottled water and powdered milk. Tea
and coffee are safe if the water has been
boiled for three minutes. Beer and bottled
wine can be taken safely, but fruit juices
should be avoided.
As for food, we advise the traveler to be sure
that both meats and vegetables are well
cooked. In undeveloped countries we advise
the traveler to ask io see the meat before it is
cooked, checking it for freshness, and if
possible, have it cooked in front of the trav
eler. In these areas meat should always he
cooked very well done and never eaten rare.
UHIA UORKF RS H.Y
Bread is usually safe anywhere but if in
doubt it can be heated. Raw salads, fruits,
and vegetables should always be avoided.
Any fruit which has a thick skin intact is
safe if it is peeled by you with a clean knife
and the skin is washed with bottled water
first.
Should the traveler become sick on a trip,
we advise the following:
For Diarrhea For the treatment of the com
mon diarrhea of the tourist we suggest
Lomotil. Kaopectate. rest, and a diet of light
tea. rice, and applesauce. We caution the tra
veler that, if diarrhea persists for more than
two days or if accompanied by fever or
bleeding, a physician should be consulted.
To find a competent physician overseas, we
suggest;
1. Checking with the company’s nearest
foreign office.
2. The nearest U.S. Consulate or British
Consulate.
3. The nearest medical school or univer
sity hospital, and
4. The International Association for
Medical Assistance To Travelers. Em
pire State Building. 350 Fifth Avenue.
Suite 5620. New York. New York.
In general, we suggest that one should avoid
foreign physicians on short trips; visits can
be a waste of time and money and in some
of the undeveloped countries they can even
be dangerous. For example, Ihe use of a dir
ty hypodermic needle spreading disease like
hepatitis is not uncommon.
Circadian Desynchronization This is a
new medical entity in which people who
travel across lime zones desynchronize or
unbalance their biological clock which
regulates their normal cycle of sleeping,
waking, eating as well as other biological
processes. This unbalance can cause a per
son to be fatigued and irritable or to have in
somnia. headaches, and lost, of appetite. It
may even cause disturbed thinking facilities
and decision making. These symptoms dis
appear after one or two days in the new lime
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zone. It is important when scheduling travel
to allow enough time for recuperation when
passing through a number of time zones.
Most people can only manage three time
zone changes. On any transoceanic flight, it
is well to allow one day for recuperation and
rest before scheduling activities. We suggest
breaking a long trip into several portions.
Schedule flights to arrive at your destination
before nightfall in order to get a good night s
sleep.
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Drugs for Intestinal Parasites In the
(Jenerol Motors Overseos I'rocrdura Monuol
we have included a reprint of Chapter 22 of
tiie book Drugs of (Jioice 797G-77 by Dr. Ben
jamin H. Kean and Dr. Donald W. Hoskins
from the Mosby Company. We included this
chapter entitled “Drugs for Intestinal
Parasitism" because it gave our company
physicians a concise outline for the standard
treatment for intestinal parasitism such as
amebiasis, trichinosis, giardiasis, hook
worm. ascariasis. tapeworm, schisto
somiasis. to name just a few. I recommend
this book heartily, especially Chapter 22.
Genera! Medical Advice The following
general advice is given to the traveler:
1. Wash and w'ear clothes do poorly in the
tropics. Oilton clothes are cooler since they
absorb moisture better.
2. In remote hotels use insect spray in the
room. Spray under the bed and around the
room for a minute or two. and leave the
room for an hour or two. Leave the room
closed with the lights out. Open the win
dows for the night.
3. Have a dental and eye check-up before
you go abroad.
4. Take sun glasses, an extra pair of regu
lar glasses, and your eye prescription with
y<»*5. Break in new shoes before you depart.
6. Take a supply of hand cleaning “Wash
Ups" package's.
7. if you experience ear pains while flying
or are flying with a cold, take one tablet of
Actifed one half hour before you board the?
plant; and use zXfrin Nasal Spray (see direc
tions).
8. Slay out of fresh waler bathing areas
unless you can be sure that they are free of
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snails. Schistosomiasis, a snail borne
parasitic disease, is second only Io malaria
as a serious parasitic infection. The most
casual contact with infected water can
transmit this disease.
9. Avoid flying with any symptoms of in
fection. i.e., temperature elevation, inn* . ear
infection.
10. If there is a history of varicose veins or
phlebitis, we advise travelers not to cross
their legs on the flight, and advise getting up
rr I walking around the plane frequently to
/.crease circulation.
11. If there is a history of digestive dis
order. travelers should 1 e cautioned so eat
and drink very sparingly or not at all during
the flight.
Mental Status Evaluation One «>i the
problems that I have encountered is the trav
eler who fears flying. The following list of
recommendations can be made Io such a
traveler:
1. We suggest that the patient read the
following two books. Hop’ ond Help ff»i Your
Nerv(?s bv Dr. Claire Wiekes and Fear of Fir
ing by Marvin Essons
2. We also explain to the patient the
pathophysiology of the fear, the “flight or
fight" syndrome. Included in this is the con
cept of sensitization of the nervous vystem
that fear produces. This sensitization causes
excess adrenalin to be produced which is
responsible for the physical symptoms that
the patient experiences, i.e.. symptoms and
sign." of hyperventilation (i.e.. pari’slhesias
of the extremities, light-headedness, syn
cope, or tachycardia), abdominal bloating,
eructation, and so forth.
3. We also attempt Io reduce anxiety by
(A) Education, reviewing: cost of airplane,
mechanical cheeks, personnel compi lence.
turbulence, sounds oi landing gear lower
ing. slowing of motors driving: (B) Picking
the right flight: daytime — good visibility
landing, good weather, large plane, i.e.. “4/
(C) Tranquilizers: (D; Relaxation exercises
and techniques, i.e.. TIM: (E) Organized oc
cupations such as conversation, puzzles,
reading, and so forth
A very careful mental status evaluation of
the employee and his family who an? being
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sent on foreign assignment should be made.
The executive whose wife and he: art! not
getting along usually do not do well on a trip
or on a new assignment. One? does not run
away from marital problems by changing
geographic locations, nor does the
geographic location change the problem that
exists between a couple. Heavy drinking can
la*come alcoholic drinking in a setting of a
new geographic location. There is a high
percentage ot alcoholism that develops m
Americans based overseas, probably
because then* is a great deal of socializing
around alcohol in the American community
overseas and very few physical and emo
tional outlets.
A careful evaluation of the social aspect'-: of
the family should be taken into considera
tion prior Io sending the employee on an
overseas assignment. Interviewing of the
f.imily members that will be going with the
employee is important. If the wife is not
happy about moving to a new country,
chances are she is not going to do well at the
new location, and second thoughts should
be given about giving medical clearance io
that particular family for an overseas assign
ment. there are no community facilities ic.i
counseling, no mental health counselors,
marriage counselors or even drug or
alcoholism counselors.
Drugs among the adolescent children should
he watched for. We do a screening test on all
adolescents I might mention that adoles
cents. in general, do not do well overseas, if
a youngster is picked up as having a drug
problem in an overseas community, the
laws are very stringeni: in the Middle East,
for example, the punishment is death or life
imprisonment. The son of the American ex
ecutive of another company m .*an. age 17
1 2. almost went to prison for life because he
had some narcotics in his possession. Nar
cotics are very plentiful and easily obtained
overseas: however, the penalty is so great
that it is unwise for a company to send a
voungster overseas who has had a history of
trouble with drugs: hence, it is important to
screen the medical history and the urines of
adolescents for drugs during the examina
tion.
UH»S
Alcoholism among the wives of some Amer
icans on foreign assignment seems to be
somewhat prevalent. We would caution the
examiner to be especially attuned to the
possibility of alcoholism among the wives of
the overseas assigned employees. Many
times a subtle alcohol problem can be dis
covered when the patient gives a history of
severe nervousness, insomnia, frequent
headaches, and the constant use of alcohol
and/or tranquilizers to reduce these
symptoms.
W'ives appear especially vulnerable since
many of them are discouraged because of
local customs or mores from working out
side or inside their own homes, and they do
not have the usual outlets of outside com
munity activities that can keep them busy.
To this is added the fact that the few' social
activities foreign-based Americans do have
usually revolve around activities when
alcohol is used in great abundance, i.e.. the
cocktail party. We have had to evacuate sev
eral families when the wife of an employee
became an alcoholic. In these cases, we used
the General Motors Alcoholism Recovery
Program as a basis for treatment since the
threat of loss of the husband s job was used
as a lever to motivate the wife into treat
ment.
It should be doted that when we send a
family overseas, the Corporation feels
responsible for the health of that entire
family as opposed to a domestic employee
whose personal life becomes his own after
his working hours are over, in other words,
when the company hires a man and sends
his family along with him. they are. in
reality, hiring the whole family. Since it has
been estimated that it costs the Corporation
three times the employee s salary to main
tain him and his family overseas, the com
pany has a great investment in the good
health of its overseas families. It is.
IhereLre. important that a careful evalua
tion of the family's health be performed
prior to the assignment being made. The
evaluation should include not only a careful
mental status but also an evaluation of the
social inter-reaction of the family, since
there is a great deal of cultural shock that an
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overseas employee and his family will be
subjected to on a foreign assignment. By
doing this, the company has a better chance
of guaranteeing a happy, healthy American
employee and family working and living on
an overseas assignment.
SUMMARY
We have tried to include in our discussion
preparation of individuals for international
travel — the physical evaluation, immuniza
tions. medications for foreign travel, and
how to obtain physicians’s care in foreign
countries. We also included travel tips in
general. We have touched on the time zone
changes that affect the traveler over long
flight distances, and we have outlined for
you what our corporation policies art? con
cerning our International Service Personnel
based overseas.
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The scheduled and supplemental U.S.
airlines are a reasonably well-defined area
of civil aviation. This is not so with respect
to business aviation and the air taxi indus
try. The reasons for this will be apparent in
a moment, but it is worthwhile to define
something of the corporate and air taxi
aircraft operations for clarity.
GENERAL AND
BUSINESS AVIATION
Robert L. Wick, Jr., M.D.
In general, aviation activity in the United
States is classified in terms of three entities.
These are: military aviation, airline ac
tivities, and general aviation. While the first
two are reasonably self-explanatory, ihe
third category is a very amorphous one and
in effect, is a classification by exclusion.
That is. anything which cannot be identified
as military or airline is therefore classified
as general aviation. It is a large area. 7 here
are approximately three quarters o! a
million pilots within the United States, and
more than 150.000 aircraft. Less than 3.000 of
these are airliners, and less than 30.000 of
the pilots are employed in scheduled airline
services.
Government regulations require very
careful documentation of airline operations,
but require almost no recordkeeping in the
general aviation sphere. Consequently, we
must estimate the size and degree of activity
in this area. We do know that almost a
quarter of a million individuals are licensed
as commercial pilots. That is. they may fly
professionally in almost every phase of avia
tion except as captains of scheduled
airliners. They can and do serve as Ihe
copilots for major air carriers. Records are
not required of these commercial pilots, and
in fact, they are known to drift in and out of
commercial aviation as their fortune, and
the economy, waxes and wanes. Estimates
vary, but a conservative guess is that about
90,000 pilots earn their living in aviation ex
clusive of air carrier^ work. Examples of jobs
these people might hold run from pilots of
airline type aircraft operated for private cor
porations to test pilots, crop dusters, air am-
WHEV WORKERS Ff.V
120
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bulance pilots, banner towers at resort
areas, flight instructors, fish spotters, power
line and pipe line patrol pilots, air show
pilots and even the pilots of the well known
Ooodyear blimps.
The area in which they fly is also one of the
factors complicating the problem of deter
mining the actual size of aviation operations
in the United States There are at present be
tween 11.000 and 12.000 registered aircraft
landing areas in the United Stales. A mere
three hundred and fifty of these have a
Federal Aviation Administration control
tower in operation. No records are required
or kept concerning operations at the remain
ing airports. Any statements concerning
aviation activity, therefore, are at best rather
tenuous estimates. As a matter of interest, it
should be noted that the airlines serve only
about 500 airports in the United States.
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The figures just mentioned are rationale for
the existence of general aviation. It is not al
ways possible to travel to any given destina
tion by airliner. Major metropolitan areas
are often served bv several airports, only
one or two of which will host the scheduled
airlines. The remaining airports may well be
located somewhat nearer to the business
center of the area, or to other attractions for
the traveler. Examples include: Chicago's
Meigs Field, just five minutes from the Loop
compared with almost an hour from busy
O'Hare Airport: Detroit City Airport; Toron
to Island Airport. Seattle's Boeing Field:
Kansas City Municipal Airport: Downtown
Airpark in Oklahoma City; Lakefront Air
port in New Orleans; Burke Lakefront in
Cleveland, and many others. The list is
almost endless. Los Angeles is a special case
in point. While the airlines serve a number
of airports in the LA. basin, there are many
more serving general aviation located all
through the basin. These include several of
the busiest in the world. Unless one's busi
ness is almost at the airline airport, there is
usually one of the smaller general aviation
airports located more conveniently to indus
try. tourist attractions, or sports areas.
Airline flight scheduler are not always con
venient either. At some of the less busy ter-
minals. airline flights are quite infrequent,
and may be as few as two or three a day. In
convenient schedules sometimes require
more than a full day to travel from one point
to another in the United States. These pres
sures and the value of a busy executives
lime, have led to the development of exten
sive air taxi and corporate flight department
networks. It is common for a large corpora
tion with highly compensated management
officials to own and operate several jet
powered aircraft to more efficiently utilize
their executive manhours. Others use air
taxi operators for the same purpose.
Air taxi services used in this manner are
likely to be jet aircraft themselves, approx
imating the speed and range capability of
many airliners. They have the additional ad
vantage of being able to use many more air
ports than are served by airliners. And they
arrive and depart at the schedule required
by their passengers rather than somewhat
arbitrary and perhaps inconvenient times.
Of course, all this costs considerably more
than the price of an airline ticket, but some
executives are worth enough to their com
panies to easily justify the additional added
expense.
These same aircraft are sometimes used for
relatively small freight shipments. Consider
the case of a large aqd expensive automobile
production line. As a result of some minor
miscalculation in ordering, imagine the costs
if the line is shut down for hours with all the
workers sitting and drawing their wages
because of a shortage of 40 left front win
dows. Il may well justify shipping those
missing parts by a special jet charter flight,
as expensive as it is. to avoid stopping the
production line.
It is obvious from the foregoing discussion
that the size of corporate and air taxi opera
tions cannot be clearly identified, but we
can consider some of the problems facing
both the pilots and their passengers. Let us
consider the passengers first. Let us further
consider those most likely found in the ex
ecutive category who will be carried on
board sophisticated jet aircraft whether cor
porate or air taxi operated.
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There aie now more turbojet airplanes oper
ated in this category than are operated by the
airlines. However, they tend to be much
smaller. Typically, they are crewed by two
pilots, and may carry from four to twelve
passengers. All are pressurized, and provide
the same emergency oxygen systems as well
as creature comforts found on their larger
airline cousins. Indeed, a number of former
jet airliners are also operated in corporate
service, but these comprise only a relative
handful compared with the typical small jet
just described.
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There is one important difference, however,
which is of vital concern. These airplanes
are almost exclusively twin engined models,
and they do not have quite the same re
liability as their larger three and four
engined relatives. At times windshields do
crack and door seals do fail. An airliner with
a large cabin volume plus three or four
engine-driven cabin compressors is not sub
jected to a rapid decompression under these
circumstances. Unfortunately, the small jet
is occasionally thus subjected, and with
great rapidity. Further, the most popular of
the small jets, the Lear, cruises at 41.000 feet
frequently, an altitude considerably above
the cruising altitude of most airliners. A
cabin decompression is therefore very
serious indeed.
The passengers seldom if ever receive an
emergency briefing from the crew. Nor is
there any hostess on board to provide one.
or assist the passenger in the case of such an
event The crew is busy with the aircraft
problem which caused the loss of cabin
pressure. The passenger is on his own. The
time of useful consciousness at these
altitudes may be as little as twelve seconds.
If the passenger does not recognize the
emergency, don the mask, and secure the re
taining strap within the alloted t'me. he is
not likely to at all until the aircraft reaches
altitudes below 20.000 feet. This in turn may
take vital minutes, and at the very least hy
poxic convulsions may be expected. Brain
damage is also possible, but is. happily, ap
parently extremely rare. /Xt best, however,
the passenger is in for an unpleasant ex
perience and possible injury.
V.HFA HORKFWS KI V
Leaving the high flying world of the jet. and
returning to somewhat more mundane pro
peller driven aircraft, we find several
different categories of airplanes. Some are
prop jets, that is. a jet engine is hooked to a
propeller. While these art? not as List as pure
jet airplanes, they may have as long or
longer a range, and most important, they are
generally able to operate! from much smaller
airports, thus opening up to them the
possibility of using the great majority of the
nation s landing areas. The prop jets tend Io
be pressurized, and therefore provide the
same comfort of the pure jets. However,
they tend to operate at considerably lower
altitudes. 20.000 feet and below, so their pas
sengers are not exposed to the same
decompression risks as those riding in the
pure jets. A complete loss of cabin pressure
at 20.000 feet, for example, would not be ex
pected to cause unconsciousness in any nor
mal individual. Ample time is available for
the aircraft to descend to lower altitudes
before the degree of hypoxia becomes more
than uncomfortable for those riding in the
cabin.
Propeller driven and piston engined planes
tend to be unpressurized. Qnlv a few ’ top ot
the line” piston powered aircraft have pres
surized cabins, and these can be classed
with ‘he jet props with respect to their loss
of cabin pressure hazards. However, any
propeller driven airplane has another prob
lem which is a significant hazard to the oc
cupants. That hazard is noise.
There are three major so: ~ces of noise with
in an aircraft cabin. These are engine noise:
aerodynamic noise, i.e.. noise generated by
airflow around the outside of the fuselage;
and propeller noise. Pure jet engines ob
viously do not have propellers, and thus we
may disregard this source of noise when
considering the corporate or air taxi jet
airplane.
These smaller jet aircraft have noise levels
within the cabin which approximate 85 dBA
or less while the airplane is al the cruise
configuration. It tends to be somewhat simi
lar to white noise, and is largely the result of
aerodynamic generation. Jet engine no.se is
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a major hazard’to those working outside on
the ground around the jet efflux, hut it does
not play any significant part in the noise pic
ture within the cabin.
The propeller driven airplane is an entirely
different story. One design limiting factor is
propeller lip speed. It must not be allowed to
become supersonic, but it does reach high
subsonic airspeeds. It generates the majority
of the noise permeating the aircraft cabin.
Surprisingly enough, engine noise is a
minor part of the noise environment found
in most cabins and cockpits. Aerodynamic
noise is similarly a small part of the ambiem
noise, in part because airspeeds tend to be
relatively low compared with jet airplanes.
Several surveys of propeller driven aircraft
common in the general aviation world indi
cate that cabin and cockpit noise levels of
100 dBA are common in the overwhelming
majority of propeller aircraft. The noise
hazard is obvious. While the casual or occa
sional passenger may not suffer permanent
damage, the busy and frequently traveling
executive takes a significant risk. It is well
known, and has been for more than 40
years, that the professional pilot usually has
a significant noise-induced hearing loss.
Data do not exist which document this for
the frequently flying executive, but it cer
tainly would not be an unexpected finding.
Thus far. we have considered only universal
hazards for the traveling executive passen
ger. There are other lesser problems facing
him as well. For example, flights in smaller
and slower aircraft tend to be confining.
Small piston powered aircraft tend to have
seating arrangements similar to that found
in passenger automobiles. Il is impossible to
get up and walk around or stretch one’s legs.
Even medium sized and so called “cabin
class’* executive aircraft have little
headroom, and will not permit an individual
of average height to stand upright although
they may have comfortable chairs. Several
of the multi million dollar corporate jets also
will not permit a six footer to stand erect.
The older executive with circulatory prob
lems. iherefore. is restricted in his move
ment. and is more prone to dependent
edema and other complications during his
air travel.
The smaller aircraft also normally do not
have any sanitary facilities. Unlike the case
with automobile, train, or airliner, toilet
facilities may not be available in any form
for a period which may exceed four hours.
The average flight duration capability in
hours of even the smallest single engine
airplane is usually this period at a minimum.
It can easily exceed eight to ten hours in
some higher performance small aircraft.
A word about helicopters is in order. They
are presently used in very small but slowly
increasing numbers for executive transport.
They are most useful for areas where air
ports are scarce or non-existent, but range
requirements are not great. Problems of hy
poxia virtual’y do not occur because the
operational altitudes of helicopters tend to
be less than 10,000 feet above sea level, and
hypoxia is not considered a significant fac
tor at these levels.
Noise levels tend to be extremely high,
however, and hearing protection is essential
for all crew members, and for all but the
most occasional passenger. However, flight
durations are short, and coupled with the
ability to land in very small areas almost
anywhere the lack of sanitary facilities' on
board presents no problem to the traveling
executive.
There are two other aspects of the traveling
executive which should be considered. We
have assumed that the traveler is in good
health. The individual with respiratory
problems, or with metabolic problems, e.g..
diabetes, may require some additional con
siderations. Respiratory disease may impose
some cabin altitude restrictions for comfort
and in some cases necessitate the use of sup
plemental oxygen. However, this is in no
way different from the case of the same in
dividual carried on board a scheduled
airliner.
The executive with a medical problem,
diabetes for example, must be aware that al
times he will be isolated from ground assisHUES' WORKERS H '
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lance for a significant period of lime
Aircraft en route through areas of bad
weather may not be able to divert and make
an emergency landing. Therefore, such an
individual must be prepared for emergency
actions should difficulty arise while air
borne.
The problem of flight within smaller aircraft
also must be considered. Some individuals
are afraid to fly under any circumstances
and in any aircraft. Others are comfortable
in larger airplanes, but may be quite ap
prehensive about flight in smaller cabins or
in very light aircraft with automobile type
interior configurations. Still others with
some degree of claustrophobia become quite
upset at the closed in tube-like effect found
in the cabins of many modern airliners. This
last problem is usually alleviated by flight in
corporate aircraft. These smaller aircraft
tend to have proportionately larger win
dows. anil because each seat is next to a
window, claustrophobia becomes a re
latively insignificant problem. The fear of
flight syndrome usually can be relieved as
the flight progresses when the passenger
sees the actions of the pilot.
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Corporate and air taxi flight crews have no
significant medical problems not also affect
ing airline crews. However, crews of pro
peller aircraft do have the aforementioned
noise problems, and in addition, the flight
durations make the lack of sanitary facilities
in the smaller airplanes a somewhat more
serious problem. It has been said that
"Hemorrhoids and a hearing loss are the
mark of the professional pilot." There is
more than a grain of truth in this statement.
Airplane accidents are also a hazard for the
flying individual. From a statistical stand
point. they are quite rare. At the same time,
the problems and data concerning occupant
protection in crashes constitute one of the
most voluminous aspects of the aeromedical
literature. A detailed discussion should
reasonably be a separate subject. However,
there is one aspect worth mentioning. That
is the subject of passenger restraint in the
case of a light aircraft accident.
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At one time, aircraft tended to be more ad
vanced than automobiles with respect to
passenger protection and restraint. At the
present time, the situation has been
reversed Seat belts have been required for
aircraft occupants for many decades. Today,
a seat belt is still the only restraint required
of any pilot or passenger. Automobiles have
rapidly passed through the stage of seat belts
only, and are today equipped not only with
seat belts, but with shoulder harnesses, in
some cases inertia reels, and in many cases
with interlock devices assuring their use.
Development work is also under way with
air bag passive protection systems.
Similarly, aircraft panels and instruments
have changed little since World War II. but
automobiles now feature recessed instru
ments. flush door handles, padded dash
boards and so forth. There is some evidence
to indicate that up to 37% of light aircraft
(defined as airplanes with takeoff weights of
less than 12.500 lbs. a class which includes
almost everything smaller than the current
corporate jets) fatalities could be prevented
by using the state-of-the-art techniques
available for passenger protection.
The remaining problems for workers who
fly are found in the more specialized types
of aviation. Perhaps the largest of these is
the field of agricultural aviation. "Crop dust
ing" is a major economic part of general
aviation. It is also a highly technical busi
ness and is carried out by professionals far
removed from the ■ barnstormer" operation
common after WW 11. The aircraft used are
highly-developed, expensive machines.
Prices for a well-equipped airplane and
agricultural application equipment necess
ary for it can easily exceed S100.000. In addi
tion to ins jct control with respect to crops,
aircraft are today used for vegetation control
of all types, mosquito control, seeding, fer
tilization. and insect control with respect to
animal husbandry.
Hazards include those of crashes. Unlike the
corporate transportation area, crashes are
common in agricultural work. The aircraft
are designed to provide maximum protec
tion in the event of a crash, and are also
124
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des^nei! to minimize the effects of striking
u'.iseen wires, and the crushing effects of the
payloads they may have on board.
A far more serious problem is that of the
chemicals applied. They tend to be toxic par
ticularly when they are used lor insect con
trol. The flight and ground crews working
with these chemicals must know the hazards
of the individual material they are applying,
and must also apply strict discipline in their
use. Protective clothing of the proper type is
absolutely essential. And in the untoward
event of an accident, specific first aid
materials must be readily at h?nd. ■ urther.
nearby medical facilities must be alerted to
the possibility of a problem with these
chemicals, and should take steps to have
necessary drugs available for treatment.
It does little good for a pilot or ground crew
man io be brought in to an emergency
department of a local hospital if the hospital
staff membars are totally unaware that the
patient, in addition to any trauma he might
have, may also be suffering from an acute
overdose of an organic phosphorous com-
pound. Nor is it any more helpful if the cor
rect diagnosis is made but the rearest sup
ply of ProtopamR is a hundred miles away
in a drug supply house storage facility.
These then are some of the problems facing
workers who fly. The list is by no means ex
haustive. but the interested and concerned
physician can begin with a study of these
problems and proceed as his interest leads.
GENERAL REFERENCES
1. Aerospace Medicine. (ed.| Hugh W. Randel
Williams and Wilkins Company. Baltimore. 1971.
2. FAA Statistical Handbook of Aviation. U.S.
Government Printing Office. Washington. D C.. 1975.
3 McFarland. RA Human Factors in Air Transporta
tion McGraw Hill Company. New York. 1953.
4. Annual Report to Congress. National Transporta
tion Safety Board. Washington. D.C.. 1975.
5. Ryan. RP Crash Injury Survival. A Report r.f 2fi
Cases.' Aerospace Medical Association. Miami. May
1976
f» U.S Naval Flight Surgeons Manual. U.S. Govern
ment Printing Office. Washington. D.C.. 196ft.
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HOW TO DO A
WALK-THROUGH SURVEY
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THE INDUSTRIAL
HYGIENIST’S
VIEWPOINT
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Marshal! E. LaNier
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From the industrial hygiene point of view, it
is important that the desired result is taken
into consideration prior to selection of the
walk-through site. In addition, it is impor
tant to consider the various personnel in
volved. The establishment s on-site in
dustrial hygienist often has more familiarity
with the process than does its corporate in
dustrial hygienist, in those states with ap
proved OSHA plans, the approach of the
State industrial hygienist may not be the
same as a Federal industrial hygienist
whether this individual is from OSHA nor
NIOSH. Similarly, an industrial hygieni&t
serving as an outside consultant from a
university may not have the same approach
as one from a private consulting agency.
The question of certification is of current in
terest. Just as physicians have specialties, in
dustrial hygienists often have special areas
of expertise. As a result of the examination
given at the 1976 Industrial Hygiene Con
ference in Atlanta, the number of board cer
tified industrial hygienists in the United
States is about 1.025. This compares with the
approximately 600 board certified occupa
tional physicians.
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Just as a note of interest, when NIOSH con
ducts an evaluation of a work site, these
icsults are not used by OSHA in citation for
an over-exposure. OSHA develops its own
information as it relates to worker exposure.
This gives me an excellent opportunity to
say a few words about the NIOSH Health
Hazard Evaluation Program. As many of
you know, the Act provides that any
employer or representative of employees
can request an evaluation of his worksite for
adverse health effects. This formal mechan
ism provides for an on-site evaluation
generally of a specific process, rather than a
plant-wide walk-through. The number of re
quests received, and those which we are
capable of providing an immediate . - spouse
to. is presently stretching our capability. It is.
therefore, advantageous to the field of oc-
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cupationa) safety and health that manpower
be developed through individuals such as
yourselves to provide assistance in this area.
What does the industrial hygienist look for
when requested to evaluate a particular es
tablishment? He must consider several
areas. He will first divide the plant accord
ing to types of operations conducted. Then it
will be necessary to look at the complete
plant layout, checking which operations are
located near other operations that may pose
a potential problem when the contaminants
from one are mixed with the contaminants
from the other. In order to do this, he must
be familiar with the material flow and pro
cedure throughout the plant. This cannot be
done without a detailed familiarity with the
chemicals at every given step.
This raises a point that probably should be
touched upon, and that is the flexibility of
purchasing given the procurement depart
ment. On a number of occasions that I have
personally witnessed, the purchasing agent
has changed a given chemical because he
could get the quantity required at a lower
price without consideration as to the comoatibility of that chemical with others in the
plant. I would strongly urge that prior to
changing chemicals in a given process, the
compatibility and toxicity of new chemicals
with others being used be considered.
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Compatibility has not been taken into con
sideration in the development of either Sec
tion 1910 OSHA standards or the American
Conference of Governmental Industrial Hy
gienists Threshold Limit Values. In each of
these lists, the permissible exposure level is
considered as a pure substance. There are
few occasions where the substances listed
will not be present with other chemicals.
Much will have to be done to establish stan
dards for work environments containing
mixtures. Although the 1910 standards list
approximately 500 chemicals, and the pre
sent Threshold Limit Value list has 611.
NIOSH s Registry of Toxic Effects of
Chemical Substances now has some 21,729
different chemicals for which there are
documented human data. Also there are
more than 61.000 cross references. Depend
ing upon the information source, there are
between 100,000 and 500.000 different
chemicals used in the various work en' ironments across this nation today. The task of
developing standards for each of these sub
stances is almost insurmountable, particu
larly at the speed we are going today.
The initial walk-through provides the in
dustrial hygienist with an opportunity to ob
serve the various processes in operation that
might be a source of contamination. His
trained eye can often spot areas of concern.
For example, the respirable particles from a
crushing or grinding operation that are most
harmful to man are those that are invisible to
the eye. Fumes are generated from an opera
tion that involves heat (such as welding or
brazing), where particles are generally less
than one micrometer in size.
The type and location of local exhaust ven
tilation: the air disturbance near the point of
entry which 'an affect the capture velocity:
the pipe sizing, shape, and corner*: which
can affect the air flow or serve as collection
points for contaminants—all of these must
be observed. What type of filter or air clean
ing equipment is used? Where is outside ex
haust in relationship to the clean air inlet? Is
the building under negative pressure
because exhausted air is not replaced with
make-up air? The evaporation of a solvent at
a dipping operation may not create a unique
odor for its detection: however. *he in
dustrial hygienist will flag suspicious areas
for later sampling.
Sampling for work environment contami
nants is still an art. In our Standards Com
pletion Program, more than 100 sampling
and analytical procedures tor those sub
stances listed in the 1910 OSHA standards
were inadequate. Laboratory experience has
demonstrated that one must carefully con
sider not only the type of operation, hut the
possible interferences present when sam
pling. and that the provision of your chemist
with a bulk sample does not necessarilv pro
vide him with the sample he needs of the
airborne situation. Industrial hygiene
chemistry is becoming a specialized field
within itself.
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A method of control most often relied upon
is personal protective equipment. Your peo
ple problems will start here, not stop. The
law suggests that protective equipment be
used only as a last resort while engineering
controls are being designed, purchased, or
installed. 1 saw a sign that said something
like "walk a mile in a man’s shoes before
you condemn him." Well, you should wear a
respirator yourself for the time period sug
gested. and you will understand why they
are often worn as a necklace. Are gloves
needed md worn? What kind are provided?
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Observe how they take them off—one with
the gloved hand, the other with the bare
hand—then put them back on. Note how the
inside of the glove can be contaminated.
In summa y. the industral hygienist starts
his walk-through with the need to evaluate a
particular site against the critera based on
his knowledge of good practice and the re
quirements of the law. His intent is to locate
potential hazards and prevent their occur
rence so that th? worker is protected.
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Industrial hygienists are specifically trained
to evaluate the work environment. Unfor
tunately. many of you probably do not have
an industrial hygienist to call upon to help
you. at least on a routine basis. Therefore,
the job of identifying potential problem
areas, which will need more intensive
evaluation by a professional industrial hy
gienist. may be up to you.
THE PHYSICIAN’S
VIEWPOINT
Donald[. Bil’maier, M.D.
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This paper cannot present or leach all
aspects of industrial hygiene, occupational
medicine and nursing, or safety. To do a
walk-through survey you ought to have some
basic grounding in at least some aspects of
those disciplines. Performing a walk
through survey *s not a natural, inborn func
tion. However there is a lot you can ac
complish simpiy by using your senses, being
inquisitive, and keeping some basic princi
ples in minu.
This is not a talk on how to do a safety in
spection. I admit io a lack of expertise in the
safety area, and leave such walk-through in
spections tc. those who do have safety exper
tise. I am sure, however, that some of the
things I will mention will also pertain to
safety inspections.
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What is a walk-through survey? Basically, it
is comparable to an office history and physi
cal examination. No complicated laboratory
procedures are done, but you take an all
around look at the workplace to identify
trouble spots or potential trouble spots. A
well done history and physical can probably
identify ninety to ninety-five percent of the
health problems an individual may have.
Likewise, a well done walk-through survt
probably will uncover ninety to ninetv-five
percent of the areas or operations wher*
health problems may be encountered in the
workplace.
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A walk-through survey is not a definitive
study. By history you may suspect anemia
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and a look at the conjunctiva may give you
further indication of low hemoglobin. A
history of mid-epigasteric pain will alert you
to look for upper G-I bleeding, but only by
further studies will you be able to get to the
cause of the problem. A walk through
survey, likewise, will help to point out a
problem; but further definitive studies, such
as industrial hygiene sampling, or physical
examination of the workers may be necess
ary.
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On the other hand, a history and physical
examination may provide enough informa
tion to make a definitive diagnosis and start
treatment. If you discover that your patient
is having typical ulcer symptoms, you may
institute treatment with no further studies. If
you smell ammonia and the workers have
definite complaints of eye and nasal irrita
tion. you can probably say there is too much
ammonia and something needs to be done,
even if you do want to get further studies for
documentation.
Some patients will come to you with minor
complaints, or if the least little thing is
wrong. Employee complaints may let you
know of areas where health problems exist.
Some employee complaints, just as some pa
tient complaints, may have nothing to do
with health problems or might be within the
range of normal. Some employees or pa
tients may know that problems exist, but for
one reason or another do not mention them
unless asked, or unless you discover them
by looking. Some employees and patients
may be unaware that they have a problem
and only by doing a thorough and systematic
history and physical examination, or in this
case a walk-through survey, will you dis
cover any abnormalities.
The title of this section is “How To Do a
Walk-Through Survey." H will also help to
address the other adverbs of the journalistic
trade, namely “who. what. when, where,
and why." We have already talked a little
about why you want to do a walk-through
survey.
There are many potential health hazards in
industry, and we need to keep an eye on
WALK-THROI’GH SI RVEY
them to make sure they do not get ou« of con
trol. A walk-through survey is one way to
define and help you learn what is normai in
the workplace and to detect actual or poten
tial work hazards. A walk-through survey
will help you learn of existing health
hazards so that corrective action may be
taken. It will establish a baseline so that you
can more effectively evaluate future prob
lems. Surveys will also help you to get to
know the operations and types of jobs, so
that if a worker comes to you for treatment
of an injury or illness, you will know from
first hand what kind of work he was doing
Besides getting to know the jobs and prod
uction operations you will get to knew the
people Seeing workers on the job may help
you to know them better and in a diffenmt
way than seeing them in the medical depart
ment or across the table at a meeting. Also, a
walk through survey can be good public re
lations. Workers may tend to question the
credibility, qualifications, or intentions of
a physician, especially if he is paid by a com
pany. and is a member of management, no
matter how competent he is or how fairly he
acts. By getting to know the workers and (he
workplace so that you can act in an unbiased
way to protect the workers' health, you can
gain the confidence of management and
employees.
One of the main points I would like to get
across is that YOU must DO the walk
through survey. There is no subsiitut'5 for
either the you or the do. If someone comes to
you for a physical examination, you cer
tainly want to be sure that they receive a
thorough examination, and you will want to
perform the examination yourself. You will
not rely on others to listen to the heart and
lungs, or palpate the abdomen. In examin
ing the workplace* you will w’ant to use the
observations and expertise of others, but
you cannot get away from the fact that it is
something you yourself must do. To h d<d?or
the point, you is the most important answer
to who should conduct the walk-through
survey. Conducting a walk-through survey
by yourself can be very worthwhile. Also
worthwhile is a walk-through survey con
ducted as a member of a group. In many
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locations, walk-through surveys are done as
part of a plant safety committee function.
The plant physician, nurse, safety man. in
dustrial hygienist (if there is one;, super
visors. and union representatives will par
ticipate. This has the advantage of providing
several areas or levels of expertise and
points of view. At least initially you will
want to enlist whatever expertise you can.
The plant engineer, chemist, or process or
quality control personnel can be very
helpful in explaining processes or defining
what chemicals are used or produced.
When do you do a walk-through survey?
First of all. you have to do it when you have
time. But if you say “I'll do it when I have the
time.” you will probably never have the
time. As a professional with occupational
health responsibilities, walk-through sur
veys should be a basic part of your activities,
and you should make sure that your
schedule contains time to conduct them.
While it may be difficult to take the time or
adjust your schedule, it will be very worth
while to have yourself included in plant
health and safety committee activities, in
cluding the walk-through surveys. After you
have learned the workplace and met the
workers, doing a walk through survey by
yourself will allow you to give more atten
tion or time to specific workers, areas, or
operations.
A walk-through survey generally implies
that you look at. or walk through, all areas of
the location. However, you can look al
specific problem areas when the need
arises. If you see a worker from a certain
area with a minor problem, you could use
the opportunity to go take a look at his
workplace. Perhaps you could take a
different route through the plant when you
go to the medical department If you provide
medical services in your private office,
rather than at a plant location, you will have
to make a more concerted effort to get your
walk-through accomplished.
Plant management may not agree or under
stand that plant visits and walk-throughs are
a necessary and integral part of providing
occupational health services. Besides selling
yourself on the idea, you may also have to
sell plant management that surveying the
workplace is an important and integral part
of your job. Putting a time for conducting a
walk-through survey on your own schedule
is one thing, but announcing your plans
ahead of time is another. Oftentimes you
will need to make plans for a walk-through
survey in advance, so that you do not waste
your time and are able to see the production
operations which you need to see. If you
conduct the survey as part of a committee, it
will be difficult to make an unannounced
survey. When doing your walk through, you
ought to see things as they normally are.
In considering when to conduct a walk
through survey you need to take into account
the nature of the production operation. A
survey at 6:00 p.m. may fit into your
schedule just fine. If workers are only in the
factory from 7:30 to 4:30, however, that is ob
viously not a good time. Many production
operations are intermittent in nature, so you
would like to schedule your walk-through
survey when the greatest number of pro
cesses are in operation. It may take several
visits to complete a survey and cover ail the
operations, but an attempt should be made
to do thisl Processes which are run only in
termittently may present some of the
greatest potential hazards. If there is work at
night or on weekends, it may be good to
make an occasional visit at these times to see
if there are any differences from normal
daytime operations. The type of operations
or the type or amount of supervision may be
significantly different on nights and
weekends. If there are fixed shifts, rather
than rotating shifts, you will get to know a
wider range of employees.
There is no general rule on how often you
should do a walk-through survey. If the fac
tory or plant has relatively stable amounts
and kinds of operations or processes, it may
be all right to perform a walk-through
survey relatively infrequently. But if the pro
cesses, people, or level of activity are con
stantly changing, you will want to do a walk
through more often.
WALK-THROUGH SURVFY
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Where do you do a walk-through survey?
The only place to do a walk-through survey
is at the worksite. You may be able to learn a
lot about production and manufacturing
operations by talking to employees and
supervisors, on the phone or silling in your
office. The only way you can learn what nor
mal operations are. or observe problems or
potential problems for yourself, is to actually
visit the work place. You cannot do this by
telephone or sitting behind your desk. There
are probably many areas where people are
werkiro and where OSHA regulations are
be. i? complied with. The tendency might be
to wri’e "deferred" or "not done" for these
portions of the walk-through. However, it is
important to do a survey of those areas,
possibly more important than surveying the
less desirable areas.
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Sometimes security precautions will make it
difficult io arrange a walk-through in certain
areas. Health and safety professionals,
however, have a legitimate right and need to
know what work people are doing and the
things they are working with. The time and
effort must be taken to make arrangements
to visit those special security areas. Initially,
and periodically thereafter, all areas should
be visited. This means walking around the
grounds, and looking outside as well as in
side. It means looking at storage areas, main
tenance areas, locker facilities, washrooms,
ha;hrooms, office areas, and even the medi
cal facility.
In doing a walk-through, it is best to start at
the beginning ai d follow the process flow to
the end. At some locations this may be very
simple with one process or line which has a
discrete beginning and end. At other loca
tions. it may be difficult because of many
separate lines or processes, or smaller lines
or processes which lead into larger lines. In
addition, most locations will have work
areas not connected with the main processes
of the work place. Maintenance, building,
and grounds are examples. After you have
conducted a few walk-through surveys of a
site, it will be less necessary to start at the
beginning and go to the end. You can con
centrate on areas that you know are likely to
be the trouble spots. It would be well.
W\LK-THRO('GH SfRVEY
however, to do formal periodic walk
throughs which follow a plan, so that you are
able to observe all areas and workers on a
periodic basis. Most plants or facilities have
some sort of layout or map. You do not nor
mally need an extremely detailed map. but
you should have one that shows the major
operations and process flow. If a site is ex
ceptionally large, or has many varied opera
tions. a map will be essential. If you have a
limited number of locations to survey, you
may want or may be able to develop a
checklist, by areas, process, or potential
hazards. Make sure that you give attention
everywhere that needs it.
1 don't think Amy Vanderbilt has written a
chapter on the etiquette of performing a
walk-through survey. However, there are
certain rules which you ought to follow. Let
ting a supervisor know you are in his area is
helpful. Many supervisors are very protec
tive of their turf and resent intrusion, if you
explain what you are doing, and why you
are there, you will probably get more
cooperation. You may also keep yourself
from walking into unexpected hazards.
Another etiquette type question is "what do
I wear?” You wouldn't normally rent a tux
edo to do a walk through survey. In most
cases your usual clothes will suffice. But if
wearing a good suit will inhibit you from
climbing, crawling, or poking your nose in
certain areas, you should give less con
sideration to your sartorial splendor, and
more to what you need to wear for a proper
walk-through survey. (I am not suggesting
that you carry coveralls in your black bag.)
Also, you will want to wear proper safety
and protective equipment for your own
good, not only for your own benefit but to
serve as a good example or reinforcement
for supervisors and employees. While many
workplaces have loaner-type protective
equipment, it may be worthwhile to invest
in some of your own equipment such as
safety glasses, shoes, and a hard hat.
Having discussed why, who. when and
where to do a walk through survey, we are
left with what and how. You can go to the
Federal Register and find the many stan
dards that OSHA has written, and which
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form the b<1sis for a safety survey. There are
relatively few standards, however, on which
you could base a health or hygiene survey, at
least of the walk-through type.
The following books can be included in an
occupational health library and will help
you in performing a walk-through survey, as
well as dealing with other occupational
health problems.
Industrial Hygiene and Toxicology: Patty.
FA (Editor). Interscience Publishers. Inc..
New York. 1958. (Although many years old.
this is still a standard text. Volume I dis
cusses basic methods of industrial hygiene,
while Volume II covers toxicology.)
Occupational Diseases. Gafafer. WM
(Editor) Public Health Service Publication
No. 1097. (This book has been in the process
of revision for four or five years, and the
new edition hopefully will be available
sometime in the future.)
The Industrial Environment - Its Evalua
tion and Control. NIOSH. 1973. (This is a
good, basic text.)
Documentation of Threshold Limit
Values. American Conference of Govern
mental Industrial Hygienists. 1971 (Supple
ment published in 1975.)
Fundamentals of Industrial Hygiene.
Olishifski. JU and FL McElroy (Editors), Na
tional Safety Council. '971.
Survey Manual. Nad ..<d Gucupdiiunal
Hazard Survey. Volume 1. HEW publication
No. (NIOSH) 74-127. 1974. (This book de
scribes the manner in which NIOSH per
sonnel are conducting detailed walk
through surveys of industry.)
If you do some homework, you w ill find that
your walk-through will be simplified as well
as more productive. We have already talked
about getting a map or plan! layout. You
should get as much information as you can
ahead of time about processes and opera
tions. It may help to do some reading on
various types of processes, and many com
panies will have technical or sales literature
which will help give you some background.
If they do not. the public library will usually
have some good basic references for almost
any type of industry.
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One of the basic parts of an occupational
health program, and one of the things that
will help you enormously in conducing a
walk-through survey is an inventory of
chemicals and materials used and produced
in the manufacturing process. In compiling
the list, you should not overlook chemicals
used in cleaning and maintenance activities.
Compiling such an inventory is easier said
than done. It is a difficult and time-consum
ing endeavor at best. Hopefully, with more
and more people becoming aware of ‘he
need, it will become easier in the future.
More and more companies, as well as
employees and health professionals are
becoming aware of the need to know what
chemicals people are working with, so that
proper precautions can be taken.
You can go to the purchasing department to
get a list of chemicals and their suppliers.
The purchasing department can also tell you
the quantities of the various chemicals used.
You may want to look more intently at
operations which use large quantities of
chemicals.
Perhaps more important than the amount
used, however, is the toxicity of the chemical
and information on how it is actually
handled. For this you will need some basic
toxicological information on the chemicals.
The material safety data sheets may be
helpful, as well as the references mentioned
previously. The manufacturer can supply
you with these. There is a lot of unevenness
in material safety data sheets: the good ones
will teil you what is in a product, and how
much, as well as giving good toxicity and
handling information: the poorer ones will
tell you very little and even give misleading
information. Armed with your knowledge of
the processes and chemicals, wearing the
proper clothes and protective equipment,
and perhaps with a guide, you are ready to
set out on your walk-through.
What do you do on a walk-through?
Basically, you use all your senses, including
your sixth sense, to determine whether there
are any actual or potential hazards for ihe
people who are working. As you walk
around the worksite, look at what workers
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are doing, where they are working. Look at
the general housekeeping. This can give you
a clue as to how well the plant is supervised
or managed. If housekeeping is sloppy,
other controls to prevent occupational in
juries or illness may also be sloppy. Look at
the labels on bags, drums, and cans. In most
cases, these may be as uninformative as the
material safety data sheets. In some cases,
however, you may discover chemicals which
somehow sneak in. that you did not know
about. You can talk to supervisors and
employees about what they are doing. You
can carefully inquire about any health prob
lems related to work. You can observe work
practices. You can observe dusts or mists.
You can observe whether protective equip
ment is used, and you may be able to ob
serve whether engineering controls are
effective, or if they are not working or have
been sidetracked. You can listen for noise,
and also listen to the comments of
employees and supervisors. You can smell
the various chemicals used.
In all probability, you will want to take notes
during your walk-through. You may find,
especially initially, that you have more ques
tions than answers. What is the chemical
you saw the workers dipping their hands
into? What was it you smelled where the
employees complained of eye and nose ir
ritation? Is the dust the employees are
breathing where they empty the bags any
problem? How hot was it back by the fur
naces? Should those employees by the press
be wearing hearing protection? Doing a
walk-through survey is only the beginning.
It will raise questions that you must answer.
As you do more and more walk-throughs,
you will be better able to spot hazards or po
tential health hazards. When you note
hazards, you need to follow up and recom
mend corrective measures. You may need to
arrange for industrial hygiene sampling.
You may want to examine employees or do
some biological monitoring. Basically you
want to do whatever is necessary to prevent
occupational illness in employees.
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WALK THROUGH SURVEY
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ROLE OFTHE
OCCUPATIONAL HEALTH
NURSE
Helen P. Onyett, R.N., B.S.
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Doctor Billmaier has just presented not only
the '’how,” but also the “who. what, when,
where, and why" in performing walk
through surveys of industrial workplaces.
While insisting to this physician audience
that YOU (the physician) must DO the walk
through survey. Doctor Billmaier also
recommends the procedure as a group ac
tivity as "part of a plant safety committee
function," and adds: "The plant physician,
nurse, safety man, industrial hygienist (if
there is one), supervisors, and union repre
sentatives will participate." This echoes
recommendations already made yesterday
afternoon at this Congress on the "Inter
disciplinary Teamwork in the Health/Safety
Professions" symposium by both the East
man staff and Mr. MacCollum of the Society
of Safety Engineers. We nurses welcome
these evidences of an era of cooperation and
good feeling among the health and safety
professions’
The occupational health nurse is often the
grass roots "den-mother" of the plant health
team. The nurse is often the only full-time
health worker, especially in the smaller
plants, working to support a cluster of parttime safety and medical people, and consul
tant industrial hygienists, toxicologists, and
other specialists. Because she/he writes
most of the accident reports, operates the
plant dispensary, checks up on use of per
sonal protective equipment, and follows up
on correction of hazards, the nurse is often
the essential coordinator of the plant s
safety/health program in all except job title.
Those worker injuries or illnesses that may
result from safety or health rule violations
most commonly first appear in the medical
department, and the nurse being in general
charge of that listening post, has the best op
portunity to alert other appropriate mem
bers of the safety/health team to needed
studies and corrective measures.
In such organized preventive programs as
safety committee meetings, walk through
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WAl.K-THROt'GH SURVEY
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surveys. <lnd health and safety education
campaigns for workers, the nurse often
finds herself and her medical department at
the center for both planning and implemen
tation of these activities. In addition, her
daily professional contacts with workers
and their supervisors keep her in constant
touch with current administrative problems
in each department that affect injury and
disease control on the job. She/he is usually
the primary portal of entry, not only into
medical care, but also into primary preven
tion of hazardous exposures. She/he fre
quently is consulted spontaneously by
workers on a wide range of health matters,
and. in the field, often knows which
workers and supervisors can be asked to
cooperate with the professional team on
constructive preventive programs.
The occupational heaiih nurse is employed
for the purpose of prevention of disease and
injury of employed workers at and through
their places of employment; she also reduces
incidence and severity of illness and injury
to the minimum. This can be accomplished
by her responsibility for making first level
diagnosis (or nursing diagnosis) of injury
and illness and referring the employee to the
physician for early treatment. In order to
determine causation of the injury and ill
ness. an -accident report must be promptly
submitted to be incorpoiated in the OSHA
101 report or on the employer's report of in
jury for workers' compensation insurance.
The supervisor s accident report often is late
or even non-existent; this necessitates ques
tioning of the employee. A walk-through
survey of the plant periodically will assist
the nurse in identifying hazardous condi
tions which may be responsible for accident
or illness.
In order to apply principles and procedures
for promotion, restoration, and maintenance
of optimum health of the employees, the
nurse emphasizes basic areas of profes
sional knowledge and skills. These subjects
are most directly concerned in planning a
plant survey. An effective occupational
health program involves the physician, the
nurse, the safety director, the* industrial hy
gienist. and medical specialists. The scope of
occupational health services is dependent
WAI.K-THKOCCH SI RVEY
♦
on the nature of occupational safety and
health hazards, accident experience, num
her. age. and sex of the work force , rates of
labor turnover, absenteeism, availability of
community medical and health resotHces.
and requirements of local, stale, and federal
legislation. The safety director and (he in
dustrial hygienist can counsel the nurse on
identification and control of environmental
hazards.
A planned walk through survey is based on
a self-analysis by the plant professionals.
Preliminary preparation is mandatory to
provide a systematic procedure for the walk
through survey. Environmental health
hazards should be identified:
1. Determine raw materials, processes,
and equipment, by-products, and products.
2. Review material properties, effecis. pro
cess flows, pressure, and temperature con
ditions.
3. Develop references, safetv data, and
Threshold Limit Values information for all
items in 1 and 2. These can be secured
through the National Safety Council. Ameri
can Industrial Hygiene Association. Ameri
can Mutual Insurance? Alliance. Menufacluring Chemists' Association, the American
Medical Association, and so forth.
4. Establish cooperative relationships
with: a. the safety specialist—he can ‘each
the nurse how Io recognize the process or
hazard and how to investigate accidents; b.
the industrial hygienist—he can leach her Io
identify potentially hazardous materials and
envin nmental conditions and can recom
mend engineering and medical contiols.
5. Collaborate with the physician and
management to develop a medical sur
veillance system for control di occupational
disease or injury.
6. Develop a list of industrial processes
itemizing operations hazardous to safely
and health.
A WALK-THROUGH PLANT SURVEY—
THE NURSE S ROLE
1. Plan plant toijr with plant supervisor
and. if available, ‘he physician, safely
specialist, and industrial hygienist.
2. Observe safety rules. Obey the signs
rui
posted for proti ctive equipment, also in
structions.
3. Be guided by your five senses to detect
hazards and harmful activities which may
affect the workers' health and welfare. I use
E E N T 1 O as my rule of thumb.
"E”—“Eye” Are the workers following
proper operative procedures? Are safety
rules obeyed? An? machine guards in place?
Is the worker wearing protective equipment
properly? Is housekeeping good? Is carbon
monoxide produced in the manufacturing
process? An employee was found un
conscious Monday morning. What are those
dusts and fumes in the plant? Employees
claim they are carcinogenic. Is lead being
heated or used in ways to produce inhalable
fumes or dust? Does the worker in the laser
department have a pre-placement retinal
photograph?
J
"E" for "Ear” Do plant operations cause
excessive noise exposure? Has a noise
survey been done? Are the peim’ssible
hours of noise exposure document’d and
complied with? Are there signs posted for
ear protection to be worn in this depart
ment? Is ear protection worn properly? Are
there baseline and periodic audiograms
recorded? How did the welding spark gel
into the worker s ear?
“N” for "Nose” Do plant odors irritate the
worker? Are vapors, gases, liquids, or solids
in harmful concentration? Is protection
(masks, respirators) indicated? Are they ap
proved by the Occupational Safety and
Health Administration, the National In
stitute for Occupational Safety and Health,
the Medical Erne ^ency Service Associates,
and so forth? What is the air concentration
of the hazardous material? Is there a medical
surveillance procedure for this hazard? Are
the environmental controls effective? What
about the sulfuric acid fumes?
“T" for "Touch” Did the worker handle
equipment properly? Is hi; wearing protec
tive equipment such as gloves or protective
cream? Is he dean? Has the worker been in
structed as to the hazard and what ne should
do in case of accidental spill of the hazar
dous material? Are there showers and water
13'1
fountains in the near vicinity of the hazar
dous material? Has the clean up procedure
been explained to the worker? What are the
hand washing and shower facilities? Is the
temperature excessive? How does the ex
treme pressure affect the worker? Is this
area marked “off limits' ?
”T" for "Taste” Is the worker eating,
smoking, chewing, or drinking at the
worksite? (Lead and mercury workers must
be instructed to refrain from eating in the
department.) Are there warnings or instruc
tions regarding the hazard? Is there a lunch
room or cafeteria where employees can eat
during break and scheduled mealtime? Is
‘he worker washing hands or showering
before meals or departun? from the plant?
What are the sanitary standards? What
about food handling facilities? Where do the
employees keep their lunch7 Is the food safe
to eat?
“O” for “Other Physiological
Effects" Check the chart Hazards of Plan’
Operations." Is the worker instructed on the
nature of the hazard? Does the sandblaster
wear protective equipment? Is the abrasive
blasting agent silica? Did the mix room at
tendant get his backache from the job? Is
this job automated? What about the
employee wearing a pacemaker? Is there a
microwave oven on the premises? Is that
cardiovascular patient on specific medica
tions which may affect his efficiency and
work production? How about the worker on
the "pill" who is complaining of dermatitis?
Has the diabetic patient been instructed on
prompt first aid attention for all injuries no
matter how minor? An employee with sev
ere kidney disease is assigned to the merc
ury or solvent operations. What do you do
about this? How about the ex-coal miner
working in the molding department? Will he
put in a claim for silicosis?
Reporting results of the survey to manage
ment for correction of the hazardous en
vironment and to the physician for medical
controls and treatment of injured or ill
employees will increase the occupational
health nurse's capability in functioning as
an occupational health nurse.
uM h THROraH SI R\M
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WOMEN AT V^ORK
Preceding page blank
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PREGNANCY
Vilmci R. Hunt, A.M.
Fifty yeais ago we could read in a publica
tion of the Women’s Bureau1 that "although
legislation on the subject shows that some
attention has been given to special hazards
to which women are exposed in industry, ii
also shows that there has been little, if any
real attempt to discover what the special
hazards are for women.” Twenty-five ye?-rs
ago. Anna M. Baetjer in her book Women m
Industry — 'I’heir I led th ond Lfficiency^ staled
that the section on mortality and fertility of
women in relation to occupation was in
cluded no! so much in the hope of present
ing any information on the subject but
rather to point out the need for investigation
in this field and to serve as a word of caution
in interpreting the data available at that time
It would seem that the warnings of the past
fifty years have come to haunt us when we
attempt to define working women as a par
ticular population-at-risk to hazards of the
work place. Can we justify the study o; a
particular population-at-risk — in the con
text of this discussion — worn. • ’■ •rkers?
As we consider other characteristics of the
work force, e g., age. race, smoking history.
v;e have little difficulty in considering them
all as appropriate subgroups for
epidemiologic investigation. The application
of such studies to the practical problems of
safety in the work place present
demographic, legal, and biological complex
ities. These complexities reach their ex
treme when regulatory agencies, industry,
and unions attempt to focus on the female
work force. And yet an examination of
epidemiologic studies, regulations, and in
dustry practices relating to ibis particular
population, women workers, g’ves little in
dication that such complexities exist. From
the biologist s vantage point, the somatic and
genetic integrity of the total population must
be considered when there is environmenta1.
including occupational, exposure to physi
cal, chemical, and biological hazards; and
examination of all groups in that population
becomes essential. Somatic effects resulting
WOMEN' AT WORK
142
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from exposure to occupational hazards are
likely to be observed differentially in
populations designated by age. race, smok
ing history, sex. and so forth; and
epidemiologic studies are frequently
directed to the identification of the most
vulnerable group in the identified populati jn-at-risk. It is surprising, then, to note that
frequently sex as a designation is not men
tioned in many studies. A review of the past
five years of journals which publish occupa
tional health studies gives the subjective im
pression that the woman worker does not
appear to be a part of the work force (in all
its variety) that is being described.-1
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It is at this stage that we can identify a
roadblock in the development of an ade
quate informal.on base concerning the oc
cupational health status of women in the
United States. Currently we do not know if
there are occupations where women are the
most, or the least vulnerable, or whether
somatic effects stem from their particular
female characteristics. To claim that women
can be ignored as a separate group epidemiologically because we have equal employ
ment opportunity laws or because standards
for permissible exposures to hazardous
substances will be stringent enough in the
dim future to protect the most vulnerable,
ocgs the question. Women have been too
frequently excluded as a group for study,
whatever their age. their race, or smoking
habits.
One of the exceptions to such a broad
generalization concerns those occupations
with radiation exposure. The extensive
studies-* of the radium dial painters (mostly
women) presented the problem of locating
women who had married, moved, remar
ried. and so forth in order to identify as accuiately as possible the population-at-risk
and to ci mpile as detailed data as possible
on each person in that population. But all the
sociologic and economic problems of this
complex study were solved in order to pro
vide, critical information for the setting of
r-idiation exposure limits during the rapid
development of the country s nuclear
capability in wartime and subsequently for
the growing nuclear industry. '1 he ex'ent of
14.1
that study has not been matched since for a
female working population. It is useful to
examine the process of risk estimation for
ionizing radiation and other hazards to
which the general population and specific
groups of workers are exposed. It is the
estimation of risk which in part influences
the setting of standards for allowable ex
posure to hazardous conditions. As we look
at radiation exposure and protection today,
particularly in the work place, the practices
and constraints are quite different from
those we find associated with other hazards.
It would be interesting to know how
historians would explain these differences.
If the philosophy of protection of the worker
from industrial hazards is far from being a
unitary concept, can futurists predict with
any accuracy the eventual impact of this re
latively new phenomenon of radiation on
the environment, including the work en
vironment? Will the impact be. much
different from that of the old familiar
dangers and the newer suspected ones?
To my knowledge, the men and women who
were exposed to excessive polonium con
tamination in the forties under the Manhat
tan Project were never followed up,
although estimates of body burden were
made and the health physics experience
contributed to subsequent radiation protec
tion reports in the early fifties. But in the six
ties came the realization that the human and
experimental animal data upon which stan
dards for public protection might be based
applied primarily to high exposure doses,
i.e.. 100 rads and above, when information
was really needed on exposures of 0.1 to 0.5
rads. A working assumption developed
among organizations concerned with radia
tion protection that there is a proportional
relation between radiation dose and the
biological effect, and that the effect would be
considered to be independent of the dose
rate in the lower ranges of exposure. The
implication is that there is no threshold, i e..
any radiation exposure may have a fmiie
possibility of being causally associated with
carcinoge ic. developmi ntal. and/or genetic
effects. The evidence is quite clear from ob
servations on both human and animal
populations that genetic and developmental
wornx \r uoRfc
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effects and several kinds of cancer can be
produced by high doses of ionizing radia
tion. As the dose diminishes, the number of
individuals affected also decreases. And in
both epidemiologic studies and laboratory
experiments we find that the dose reaches a
point below which there are ao few iden
tifiable cases that they cannot be differenti
ated from the background noise.5
The National Council on Radiation Protec
tion and Measurements (a non-profit cor
poration chartered by Congress) recently
published a report. “Review of the Current
Stale of Radiation Protection Philosophy."
w hich analyzed the reports published since
1970 by the International Commission on
Radiological Protection and the National
Academy of Sciences of the United States.6
This is the continuation of a process of reevaluation which has gone on for more than
30 years. Whatever one s judgment of the
particular standards set and the efficiency
and vigor of enlorcement of the standards,
the process of standard setting during the 80
odd years since the introduction of ionizing
radiation into the work place bears com
parison with the standard setting pro
cedures for other physical and chemical
agents. The current guiding principle of the
National Council on Radiation Protection
(NCRP). which undergoes continual review
and which has most strongly influenced the
setting of numerical radiation protection
guides or dose limits for occupational ex
posure. is that the “lowest practicable radia
tion level" is the concept basic to the estab
lishment of radiation standards. In addition,
the assumption is made that radiation health
hazards do not have a dose threshold. In
other words, numerical radiation protection
guides or dose limits for the exposure of
radiation workers are provided only as up
per limits, with the expectation that all ex
posures will be kept to a practicable
minimum, far below what is allowable.
As a working philosophy how does that ap
ply to the fertile woman? Although the
larger proportion ot fertile women who
work in a radiation environment are hospi
tal workers, more women are entering the
nuclear industry, and we have new occupa
tions appearing, e.g.. airline baggage inspecUOKO \ \T
tion. The appendix to the National Radiation
Commission Regulatory Guide 8.137 applies
to workers employed in facilities licensed
under the U.S. Atomic Energy .Act. and
stems from a proposed amendment to Sec
tion 19.12. 10CER Part 19 that would require
NRC licensees to include instructions 'o all
workers, information about the biological
risks to embryos or fetuses exposed to ioniz
ing radiation, and in addition to advise
women employed in jobs involving radia
tion exposure that the intent is to minimize
exposure to and possible adverse effects on
embryos or fetuses. The proposed amend
ment also states that licensees should make
particular efforts to keep the radiation ex
posure of an embryo or fetus to the very
lowest practicable level during the entire
gestation period. This recent concern arise?
from a recommendation made several years
ago by the National Council on Radiation
Protectionfl that during the entire gestation
period the maximum permissible dose
equivalent to the fetus from occupational ex
posure of the expectant mother should not
exceed 0.5 REM. i.e.. one tenth the max
imum permissible dose allowed the worker.
5 REM. The comment that went with the
recommendation was that. The need to
minimize exposure of the embryo and fetus
is paramount. It becomes the controlling fac
tor in the occupational exposure of fertile
women. In effect, this implies that such
women should be employed only in situa
tions where the annual dose accumulation «s
unlikely to exceed 2 or 3 REMS and is ac
quired at a more or less steady rate. In such
cases, the probability of the dose to a fetus
exceeding 0.5 REM before a pregnancy is
recognized is negligible. Once a pregnancy
is known, the actual approximate dose can
be reviewed to see if work can be continued
within the framework of the limit set above.
The method of application (of the recom
mendation) is speculative and needs »o be
tested for practicality in a wde rangt of oc
cupational circumstances. Eor conceptual
purposes the chosen dose limit essentially
functions to treat the unborn child as a
member of the public involuntarily brought
into controlled areas. The Nt'RP recom
mends vigorous efforts «o keep exposure of
an embryo or fetus to the very lowest prac
ticable level. ”
144
Rather than pursue the pros and cons of this
approach to protection of the fetus. I want to
pick up the thread of discourse with which 1
began, namely that the extent ol the danger
which can result from radiation exposure is
acknowledged, and that practical means of
avoiding exposure to the fetus are being
developed. In addition, the central principle
of keeping exposure as .ow as practicable is
being emphasized, even .f that exposure is
already well below the maximum permissi
ble dose. Is it possible to identify some
aspects of the radiation experience which
might be useful in other occupational set
tings? What are (he current dr iciencies in
practice and knowledge?
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Although individual monitoring for radia
tion exposure has been a regular procedure
for many years, it is only very recently that
hospitals have started to become more
responsible in their checking of exposure
records They are still irresponsible in their
lack of instructional programs for
employees regarding occupational hazards.
The National Institute for Occuaptional
Safety and Health (MOSH) study on hospi
tal occupational health services showed that
in the hospitals reporting. 64% of the small
hospitals. 40% of the medium hospitals, and
30% of large hospitals had no routine in-ser
vice training programs for the control of
radiation exposure.9 Many of these institu
tions are not NRG licensees, but are nowunder the jurisdiction of the Occupational
Safety and Health Act (OSHA). Less than
2% of the more than 5.000 hospitals queried
replied that pregnancy received any
emphasis in their safety and health educa
tion programs. Setter work practices are
going to have to be demanded of health pro
fessionals as is currently expected of NRG
licensees. It is ironic that epidemiologic
studies of the longevity, morbidity, and mor
tality of radiologists (usually excluding the
few who were female) have been going on
for 20 years; but there are no U.S. studies of
X-ray technicians, nuclear medicine tech
nologists. or nurses dealing with radiation
therapy. Who knows what their reproduc
tive experience has been these last 30 or 40
years? And how much more efficiently and
expeditiously improved exposure standards
could have been introduced if these studies
had been available?
The futurist view is that we will move
toward a biological and epidemiologic1.! un
derstanding of cancer susceptibility, includ
ing particular sub-groups in the workplace.
The influences that make for differences in
susceptibility in humans are little known,
though the evidence for a relationship with
impairment of immune reactions is strong,
stronger perhaps than the evidence relating
childhood leukemia to radiation exposure in
utero at low doses of a few rads.5 The real
practical usefulness of "low as practicable
should become apparent more quickly and
directly as more hazardous substances for
which "zero exposure" is necessary come to
be identified. In addition to considerations
of potential carcinogenicity, hazardous
substances are now being tested for
mutagenicity. The experience with ionizing
radiation goes back to Herman Muller’s
drosophila experiments of fifty years ago.*°
But estimates of genetic risks in human
populations are still based primarily on ex
perimental animal data and the assumptions
of the linear hypothesis 1 mentioned earlier.
The genetically significant impact on subse
quent generations which can result from ex
posure of a population to mutagenic agents
is affected by the contribution to the gene
pool of both men and women who procre
ate. But we are a long way from knowing
whether there is a differential genetic effect
on developing ancf mature ova and sperm as
a result of old familiar hazards, least of all
the multitude of new chemical, biological,
and physical agents now in the workplace.**
Today the number of women in the work
force (and in many specific industries) is
not a limiting factor for adequate
epidemiologic study. Indeed only a few in
dustrialized countries have a total work
force of men and women which exceeds
that of working women in the United
States.12 For example, it has been found
feasible in England to make a cohort study
of female asbestos workers.,J A populationat-risk which has been virtually ignored for
50 years is made up of the children of
workers. The National Center for Health
Statistics*-* reported that in 19G3 for legitiHOMES A7 WORK
145
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niuie live births almost one-third of the
mothers were employed at some time durin;;
pregnancy. /Xmong those tor whom this was
the first live birth. 59% were employed, and
among those who had had previous live
births. 22% were employed. It is somewhat
surprising to note that for the sample of
4.000 mothers from which these estimates
wi*re made, specific information on their oc
cupation was not solicited, although that on
their husband’s was. It may well be th.it
Harriet Presser’s comment15 that the work
ing woman, and most particularly the work
ing mother has been, "one of America s best
kept secrets" is even more applicable * » the
6’)% of primiparae and 22% of multiparae
Who work at some time during their preg
nancy. We do not know their distribution In
occupation or industry. Any specific ques
tion we ask today concerning a particular oc
cupation. e.g.. X-ray or nuclear medicine
technologist, laboratory worker phar
maceutical processor, textile worker cannot
be answered. The recent studies on operat
ing room personnel and their pregnancy
outcome have now been extended to the
unexposed wives.16 We are learning the
hard way of the inadequacy of monitoring
procedures appropriate for the identification
of an additional population-at-risk — the
children of workers.
During healthy pregnancy different
reference standards of normality an* esseniiai. Al the same time, we know that the norm.’l can merge gradually into a pathologic
condition with the boundary being difficult
to diagnose clinically.17 z\ complicating fac
tor is that many of the physiological changes
found in pregnancy simulate pathology m
the non-pregnant state, (eg., edema —
swelling of ankles, and so forth) Many of
the metabolic adjustments of pregnancy are
established—often completely—during the
eailv weeks and months of pregnancy,
when the product of conception is still too
small to make significant demands on
m.it’ rnal reserves. It is useful to note th,it
physiologists no longer consider maternal
changes as reactions to "stress’’ or to depleti >n of reserve by the fetus. ’This is not to say
that these known modifications of maternal
body function from conception to the birth
>f the infant can be ignored when condi
tions in the work place diret.tly impinge on
the pregnant woman For example,
respiratory function undergoes some
(h.mges in pregnancy. rXlthough vital
capacity probably does not change, there is a
marked rise in tidal volume throughout
pregnancy. The ini rease in tidal volume in
pregnancy can increase 39% over post-partum levels.t« (aigell found the mean tidal
volume al term to be 678 ml compared to 487
mi posl-partum. The respiratory rate,
how ever, rises very little, if at all in pregnan
cy. The minute ventila’ion. because of the
tidal volume increase, shows a rise in preg
nancy of over 3 liters, about 42% . These ob
servations show that the pregnant wofhan
int reuses ventilation by breathing more
deeply and not more frequently, and minute
aheolar ventilation a! term w ill be 8.6 liters,
an increase of 65% over the 5.2 liters post
partum. If the vital capacity is unchanged by
pregnancy, there must b<? a rearrangement
of respiratory compartments: the inspiratory
capacity increases at the? expense of the ex
piratory reserve, so that the lung is relatively
more collapsed at the end of a normal ex
piration. The residual volume is reduced.
Moya el al 1!’ point out that the alveolar ten
sion of each inspired breath of gas depends
on the degree of dilution by the functional
residual air volume. This volume usually
ads as a buffer Io changes in normal
respiratory gas tension as well as gas ten
sion of an anesthetic or noxious gas. The
larger the residual volume, the more slowly
the change in concentration occurs. Conver
sely. the pregnant woman with her smaller
functional residual capacity, will more
readily and rapidly fill her lungs w ith an ad
ventitious gas at a certain tension than the
non-pregnant. In other words, a decreased
functional residual volume accelerates the
rise of alveolar concentration of the con
taminanl by reducing lung washout time.
The effect on alveolar concentration is
thought Io be greatest with the less soluble
gases, and least with the highly soluble
gases
1'hf rise in alveolar crnt.entralior prod
uction by ventilation is opposed by uptake of
the gas into the pulmonary Blood. The
greater the loss the lower is the ensuing
.dveoLir concentration. There are several
14b
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factors which determine the extent of up
aware that the fat content of blood is raised
take:
during jiregnancy. and increases have been
The solubility ot a gas is primarilv depen
dent upon the nature of the sohent and an\
variation in composition of the solvent alters
solubility.
Total lipids are im reused
lt>’ .
during pregnancy, with an elevation of over
100% in neutral fat and about 25".’> m
phosophobpids and i holesterol Howewr
little is known about the solubility of gase>
in the blood of pregnant women
including
those commonly used as anesthetic agents
such
as
chloroform,
methox vfluoranv.
halothane and t'ichloroi'thvh nc
Cardiac output governs pulmona'V blood
flow which (am remove gas from the ilveoh
Therefore, the greater the cardiac outi ut the
more rapid the absorjition o* th. gas from
the alveoli. \\ ith soluble g.ises such as ether
and halothane, an increase in i ardi.ic output
results in a considerable redin lion in .ilo-o-
lar tension and increased absorption of the
gas. z\nd during pregnanes the significant
and progressive increase m cardi.ii output
reaches a maximum of ibout Ul"> by the
25th and 27lh week. Th* se fat tors of ill
altered blood volume.1, and composition a id
(2) altered lung function must affui I i;-,e
maternal and fetal response to contami
nants. There does appear to be a theoretual
possibility that the absorjilion of contami
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nants. particularly those which follow tli*1
inhalation route. ma\ be im.reased nver that
expelienced in the non-pregnant state for
the same exposure level
reported from between (>50 Io 700 mg/100 ml
serum at 10 weeks to over 1000 mg/100 mi at
the end of pregnancy. The total lipid is
measured as that soluble in solvents such as
petroleum ether. In addition, the accumula
tion of maternal body fat during pregnancy,
particularly during the first half of pregnan
cy can make up 25% of the total weight gain
associated with the development of the
fetus. The purpose of maternal iat storage >s
important to consider— particularly in iela
tion Io fat soluble solvents. The fat store at 30
weeks gestation is about 3 1/2 kg. which is
almost half the total energy requirement
specific
to
pregnancy.
In
our
American
society the healthy pregnant woman enters
the last third of pregnancy with a very con
siderable buffer against food deprivation.
She probably needs no such safety measure:
but
many,
jjossibly
the
majority
of the
world s pregnant women, do manual labor
until the day they deliver. A further use for
the store which remains at the end of preg
nancy is as a subsidy for lactation, when*
energy
requirements
greater
than
those
of
are
considerably
pri’gnancy.
The
biological significance of labile stores of
body fat is not known, at least in the context
of industrial exposure. Hardy20 concludts
that toxic chemicals stored in fat am proba
bly l.irgely inactive. These physiologic con
siderations raise more questions for th;? tox
icologist and industrial hygienist than (hey
answer.
During pregn.incy. the concentration ot i»-d
of
How do we answer the question, “is the
hemoglobin, falls because the ini rcase o!
pregnant woman herself more vulnerable to
plasma volume is relatively greater than the
some conditions in the workplace than : he
cells
in
the
blood
and
th*Tef(»r»*
increase of red cell volum* . A comin.-n
might Be — if not pregnant?*' The com
description is the "physiological anemia of
pregnancy." which is a contradiction in
parison is not with other workers— such as
terms because these ch.mgcs in red (,<11
volume and plasma volume arc < ;itii*’lv ap
propriate to the changed < ir< uinstanciA of
pregnancy, and probably th** margin
safely for oxygen carriage is rai
of
However, it is difficult to extiapolatc Io
dilions where th** pregnant woman is ex
posed t'‘ < arbun moncxulo or nu-’hxh t’1*
chloride, for ex.imple on the basis • (
theoretical consideration^
unil.irtv. we .ire
the highly vulnerable middle-aged, slightly
over obese male, or the individual with occu pa t ion a I ly and/or tobacco-indu* ed
respiratory impairment. The integrity of the
placenta can seemingly be affected by a
variety of circumstances — most, if not all
(june inadequately understood. Maternal
blood coagulation characteristics are a case
in point. But it is not known whether fibrin
formation in pregnant women is conlinoous. possibly at the placental inter-
5
147
a
tr H«ikk
villous surface or intermittent — associated
with episodes of bleeding from the placenta.
The prevention of micro-circulatory
blockade depends, in part, on the ability of
the woman lo generate further supplies of
plasminogen activator. There is al least one
study2’ which shows that in the context of
work, a significant proportion of normal
pregnant women m the third trimester ap
pear to lose their ability to release systemic
plasminogen activator following simple
physical exercise. Such women may
therefore be at risk tc episodes of severe in
travascular coagulation. But we have little
further to go on and no linkage information
until we reach lhe clinical sector and
epidemiologic observations of pathologic
conditions such as premature rupture of
membranes, placenta abruption, and pla
centa previa. There is no doubt that many
detrimental substances in the maternal
bloodstream can readily reach the embryo
and fetus via the placenta.22 However, we
know little of the factors that determine
rates of transport of different types of
chemicals at different times in gestation.
Probably the placenta transmits to the con
ceptus some fraction of almost all sub
stances in the maternal blood plasma, but
the rates must vary w'idely. Molecules of
large size or that bear high electrical charge
are likely to be excluded by the placenta.
Some foreign substances may be excluded
or their passage impeded; for others the pla
centa may facilitate their transfer. Research
in the area of transfer rates for the placenta
is limited and has been concerned with ad
vanced fetal development, whereas the.
greatest teratogenic risk is during embryonic
stages. We do not know what concentration
of a teratogenic agent the embryo or fetus
can tolerate before damage occurs.
J}
The effect of maternal work on the fetus 1 as
been examined by Pokorny and Rous.23
Fluctuation of the heart sounds of the fetus
in 12 pregnant women was measured in the
last four weeks of a physiological pregnan
cy. It appeared that the sounds of the fetus
during dosed ' physical work of the mother
increased io a maximum in the third minute
when a steady state was reached. In the
restitution period it gradually returned to the
value at rest. However, all the pregnant
ttOMFS' AT WORK
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women did not react uniformly to the work
effort, and three types of reaction were de
scribed:
1. Feta! heart rates were practically
unaffected by physical effort. Pokorny
presumes that these women were well
adapted to the work, which was confirmed
by the slight heart rate change in the women.
2. Fetal heart rates gradually increased
with a maximum at the beginning of the
steady state. Yet towards the end of the
effort the fetal heart rate decreased to the
starting value.
3. There was acceleration of the fetal heart
rate with a maximum toward the end of the
effort, but with a marked decrease below the
starting value at the beginning of the restitu
tion period. A similar pattern is often found
in the mother s heart rate.
Pokorny ef a! considered th<* possibility that
these examples represent three qualitative
types, or perhaps only variable deviation,
and that the greater the reaction of the preg
nant women to work, the greater its in
fluence on the fetal heart rate. Under the
conditions of physical work, the fetus would
have an advantage in those women who are
physically fit. In examining pathological
pregnancies (toxemia of pregnancy and
diabetes), the change in fetal heart rate was
in marked contrast to those in normal preg
nancies. There was conspicuous increase in
the fetal heart rate’even in the first phases of
the effort (exceeding the limits of 2 standard
deviations for physiological pregnancies)
and it continued to increase until the end of
the work without reaching a steady state.
During the restitution period the fetal heart
rate fell below the initial value with a slow
return to the initial value within 5 minutes.
Pokorny concluded. "In muscular work, we
must consider the poss:bility of a diminu
tion of the oxygenated blood supply lo the
uterus because of the redistribution of blood
from inactive tissues to the active muscles.
The influence of this change in the blood
supply on the fetus may be different accord
ing to whether the pregnancy is physiologi
cal or pathological or according to the mater
nal adaptation to physical work. Moreover,
an increased physical effort may disclose a
pathological state which is compensated al
rest.”
14H
This evaluation of the range of variability in
pregnancy should be of prime concern to
those who are responsible for the physical
well-being of women and to those who
monitor their workplaces. On the one hand
we can see the continuing need for im
proved physical conditioning of women.
With the obvious increase in exercise and
sports participation by young women there
should be further research interest in exer
cise and stress physiology directed to
women. Physiologists dealing with exercise
testing are well aware that the poor perform
ance of an exercise test, by itself, does not
tell whether the subject is sick or is simply
unfit. i:e.. a poor aptitude for exercise/work
during pregnancy may be due to the lack of
physical training in association with the ad
ditional physiologic demands of that preg
nancy. 1 am proposing that the information
we derive from exercise testing and sports
medicine can he considered in light of the
European view of recent times. "Pregnancy,
far from being an illness, should be con
sidered an intensive day and night. 9-month
period of physical conditioning because of
the increased demands upon metabolism
and the entire cardiovascular system.”24
CONCLUSION
i
The evaluation of the health of women
workers as part of the total work force is
necessary for the identification and com
parison of their response to occupational
hazards. Currently it is not possible to iden
tify those industries where women workers
are more or less likely to be affected ad
versely. when compared to men. In the
future, the result can be on the one hand, ex
treme protective measures directed to
women workers which may be quite un
justified or. on the other hand, inadequate
consideration of their particular charac
teristics when criteria for standard setting
are being developed. The occupational ex
posure of the pregnant mother to hazards
potentially dangerous to the embryo has not
been examined in sufficient detail to allow
any reliable decisions. The critical decisions
concerning job opportunity and security for
women can only be made when there is con
sidered judgment of the advantages and dis
advantages of her work participation. Partic-
ular occupational conditions dangerous to
women are both real and imagined. Due to
inadequate monitoring and evaluation of
this group of workers, the difference is
scarcely known. Safety in the workplace is
far from absolute and we know that over a
million of the babies born this year will have
been in the work place at some time during
gestation.3 And. their mothers and their
fathers probably may have had the same ex
perience. For contrary to popular opinions,
we are not observing a new social
phenomenon. Women have always worked.
Indeed reproduction and work are women’s
lot.
REFERENCES
1. ’ Thf Employment of Women in Hazardous In
dustries in the Unileu States." Women s Bureau U.S
Department of l>ihor. 1919
2. Baetjer. AM Women in Industry — Their Health
and Efficiency. W. B. Saunders Co . Philadelphia. 194(1.
3. Hunt. VR ‘ Reproduction and Work
SIGNS. |
Women in Culture and Society. 1:543-552. 1975.
4. Maletskos. C| el al. ■•Quantitative Evaluation of
Dose-Response Relationships in Human Bemps with
Skeletal Burdens of Radium 226 amt Radium 228"
Assessment of Radioactivity in Man. Vol IL 225-252.
Proceedings Symposium. Heidelberg U\EA. Vienna.
1964.
5. Warren S "Effects of Low Levels of Radiation on
Rodents and Potential Effects in Man Health Physi< s
29:251-255. 1975
6. Review of the (airrent State of Radiation Protec
tion Philosophy National Council on Radiation Protec
tion and Measurement Report No 43. 1975
7. Appendix to Regulatory Guide 813 US Nuclear
Regulatory Commission Title 10. Part 19 and 20 of (.ode
of Federal Regulations
8
Basic Radiation
Protection Criteria
National
Council on Radiation Protection and Measurements Re
port No. 39. 1971
9. Hospital Occupational Health Services Stuilv 1
Environmental Health and Safety Control U S. Depart
ment of HEW PHS-CDC-NIOSH. 1974
10
Muller
HF "Artificial Transmutation of the
Gene." Science 66 84. 1927.
11 Report of the Advisory Committee on the Budogi
cal Effects of Ionizing Radiation The Effects on
Populations of Exposure tn Low Levels -if Ionizing
Radiation National Academy of Snences National
Research Council. Washington. DC" 1972
12. 1975 Handbook on Women Workers US
Department .»f Labor. Employment Standards AdmmIWMf V 5T WORK
149
L
istration. Woman’s Bureau Bulletin 297. Washington.
DC 1975.
13 Newhouse. Ml. et al "A Studv of the Mortality of
Female Asbestos Workers" Brit | Ind Med 29:134-141.
1972
14. Employment During Pregnancy Legiti nate Live
Births U.S 1963. National Center for Health Statistics.
Vital and Health Statistics. PHS Publ. No 1000. Series
22. No. 7. 19GH
15 Presser. liB Perfect Fertility Control: Conse
quences for Women and Family." led) C.E Westoff
and others. Toward the End of Growth Population in
Amerira Prentice Hall. Inc.. Englewood Cliffs. N.J..
1973.
IB Knill Jones RP B| Newman and AA Spence
Anesthetic Practice and Pregnancy-Controlled Survey
of Male Anesthetists in the United Kingdom. Lancet
2:7-9 1975
17 Hytlen. FE and I Leitch The Physiology of
Human Pregnancy. 2nd Ed Blackwell. Oxford. 19/1.
1H. Cugell. DH et al Pulmonary Function in Preg
nancy: Serial Observations in Normal Women " Am
Rev Tuberc 67:568-597. 1953
19. Moya. F et al. "Uptake. Distribution and Placen
tal Transport of Drugs and Anesthetics.
Anesthesiology 26:465-476. 1965.
20. Hamilton. A and HL Hardy Industrial Tox
icology. 3rd Ed p 362. Publishing Sciences Group. Inc..
Acton. MA. 1974.
21. Woodfield. DC et al "Serum Fibrin Degradation
Products Throughout Normal Pregnancy Brit Med J
4:665-668. 1968.
22. Wdson. |G "Environmental Effects on Develop
mental Teratology." (ed) N S. Ar.sali Pathophyi.idlngy of
Gestation. Vol. 2. Academic. N.Y.. 1972
23. Pokorny. J and | Rous "The Effect of Mother s
Work on Fetal Heart Sounds " Proc. Intern! Symp lntra-Uterme Dangers of the Fetus’ Exerpta Med.. 1967.
24. Klaus. E| and H Noack Frau und Sport. Stuttgart:
George Thieme Verlag. 1961.
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150
HOMFV AT WOKK
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The views 1 am about to state are my own.
They do not necessarily represent the views
of the Solicitor of Labor or other Department
of Labor officials.
The problem of assuring adequate protec
tion to women of child-bearing capacity
while at the same time providing women
with equal employment opportunity is. from
all points of view, a complex problem.
MAKING
THE WORKPLACE
SAFE
FOR WHOM?
Kathleen M. Lucas, J.D.
A national debate has emerged over the sig
nificance and consequences of the develop
ment of scientific evidence suggesting that
embryos during the fi.st six to eight weeks
of life are highly susceptible to the toxicity of
particular substances: that the ohspring of
women who are exposed to particular sub
stances suffer a higher incidence of birth
defects and deaths than do the offspring of
men who are similarly exposed, but that the
offspring of such men suffer a higher inci
dence than do .'hose in the general popula
tion: that the dangers associated with some
substances are no. eliminated when ex
posure ceases because such substances are
cumulative in the body; and. that some toxic
substances are transplacental.
In general, researchers and employers have
focused their attention onto the health of the
fetus within the working environment of
women, the childbearing sex. For good
reasons, women workers of childbearing
age and capacity fear that the increased con
cern in protecting fetuses may lead to their
removal from jobs involving exposure to
substances which are known or are
suspected to cause injury to the fetus.
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Many women’s groups maintain that the
focus should not be on women workers
because many substances are suspected of
causing damage to the reproductive systems
and the offspring of both sexes. These
groups also assert that the pattern of con
ducting research primarily on the offspring
W(»M»A \> H<'MK
151
La.W JtL
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of women workers is. in itself, discriminato
ry treatment. The defendttrs of the research
respond by saying that because the offspring
of women suffer the higher incidence of
birth defects and deaths, studying me
offspring of women workers is the first
priority. Representatives of women s groups
arc also questioning whether an employer's
failure to eliminate the likelihood of ex
posure or to reduce exposure to a level
which is safe for fetuses as well as adults
constitutes a violation of lhe Occupational
Safely and Health Act.
Second. I am not convinced that without
knowing the dangers, the safely levels, and
lhe feasibility of protecting employees and
fetuses tnat OSH A could ever promulgate
standards which would make all workplaces
safe for employees and fetuses. I believe that
after the scientists establish the facts. OSHA
might be able to formulate workable stan
dards which would adequately protect the
reproductive systems of males and females
but that due Io the high susceptibility of
hjluses. there are some woik placets which
simply can never be made safe for fetuses.
Before 1 explore the OSH A aspects. 1 want
Io point out the third concern raised by the
representatives of women workers which is
perhaps the most difficult. It is whether the?
reni(>vai of women workers from jobs in
volving exposure to toxic substances known
or suspected of causing injury to a female's
future offspring is prohibited discriminatory
treatment.
Third, at lhe bottom line. tl.e hazards exist
regardless of OSHA. and an employers
liability exists independent of OSHA. Given
lhe present state? of tin? law. ar em’doyer
would generally be held liable to a child for
prenatal injury which resulted from either
the employer’s negligence which has not yet
been defined within this context or from an
inherently dangerous object, a classification
which could conceivably include toxic sub
stances.
Returning to lhe Occupationaly Safely and
Health At <. 1 believe that it is loo simplistic
to say that OS1 i.A should always set lhe stan
dards a* the lowest level, lhe level which is
safe for fetuses because not all workplaci’s
can be made? safe 1 •>’• letuses. Based on th<?
following three reasons 1 believe that it is
naive to say that ihe total burden is on
OSHA i<» require employers to make
workplaces safe lor employees and for
fetuses.
First, at this lime, we do not know the* range
and scope of the dangers to employees and
their future offspring resulting from
different levels of exposure to various toxic
substances. We do not know how the?
reproductive systems of men and women
are affected much less how they can be ade
quately protected. We cannot define* the
classes of women or of men whose
reproductive systems or offspring are en
dangered if they are exposed Io individual
substances and the variance in effects al
par! iciilar levels of exposure. We have little
data on those substances which affect male
sterility or other aspects of the male
repioductive system.
lUIMF S AT WORK
/
In order Io understand lhe extent of an
employer s liability, let us look al lhe princi
ples established by lhe lines of cases related
to an employer’s liability for fetal injury. It
should be noted here that ihe Workmen's
Compensation Acts control an employee's
causes of action against an employer. So. the
question is an employer's liability to the
fetus, which is not considered an employee
within ihe meaning of those Acts. The facts
are: a women knowingly accepts a job which
involves exposure to a toxic substance
known to cause serious damage to embryos
and fetuses. She becomes pregnant while on
the job. She decides not to have an abortion
and Io bear the child.
First, is to the rights of the parent. If the
child is born alive, an action may be brought
by him or by the parents for damages Io
compensate for lhe consequences of the pre
natal injury. If the child dies, a wrongful
death action may be brought by the parents.
The parent s own contributory negligence or
assumption of risk, however, may in some
jurisdictions defeat his recovery for the
152
resulting injury to the child, hut will not in
terfen? with the child’s right to recovery.
Thus, it appears that a parent s consent may
not preclude the child’s recovery.
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Second, as to the rights of the fetus.
Historically, most jurisdictions have allowed
the recovery of damages for injuries in
flicted upon an unborn child even though
the injury occurred during the early weeks
of the mother's pregnancy.
*
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Let us add a new factor to the hypothetical,
the employee signed a waiver of the right to
sue for herself and her offspring. What is the
result? In most states, a parent may waive
her right to r<?cover for injuries to the child
but may not defeat the r’.i.ld's right to
recover for its own physical injury resulting
from the wrongful conduct of another. In
those states, a parent is not viewed as the
agent of the child for the purpose of waiving
tort liability resulting from the actions of
another. It should be noted that courts have
generally held that right-to-sue waivers
should be strictly construed.
i
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Further, it is not clear whether an employer
in a suit brought by a fetus or its next of kin
on its behalf would be considered negligent,
as a matter of law. in assigning, or indeed
allowing, a potential mother or father to
work at a job in which the employee is ex
posed to toxic substances which are
suspected to cause damage to the employee’s
offspring.
In another area of tort law. courts have held
that a person, company, or manufacturer is
liable for the damage resulting from an in
herently dangerous object, a classification
which may include some toxic substances.
The fetus might win on this-argument. 1 hus.
a suit by tht? fetus against an employer for
damages resulting from exposure to a toxic
substance could be brought as a tort action
outside of the Workmen’s Compensation
Acts, based upon a negligence or an ab
solute liability theory. The amount of the
recovery could be an enormous sum of
money, to say nothing of the unhappy social
impact of propagating a group of malformed
children. Thus, the issues are broader than
153
OSH A and the problems cannot be simply
and finally n?solved through legal deter
minations. The law does not provide ade
quate answers because this area of the law is
unique and undeveloped. The moral and
social aspects of the health of future gent'rations cannot be ignored.
At the same time, the counterbalancing
thrust is that women themselves have a right
to employment. Given an employer’s poten
tial tort liability to a fetus, knowing the
possibility of a danger is not enough to
eliminate its potential liability for dis
crimination. To satisfy Equal Employment
Opportunit” principles, an employer must
at least define the excludi’d class as nar
rowly as possible.
But what does that mean? Would the follow
ing category be acceptable: all persons
whose reproductive organs will be damaged
by exposure to a substance and who are of
an age or inclination to father or bear
children? Must it apply to men and women?
What if a woman accidentally gets pregnant
and decides not to abort even though prior to
her pregnancy she had agreed to have an
abortion? k her assurance enough to protect
an employer from liability to the fetus? Pro
bably not. V‘/ha‘. If both she and her husband
signed a waiver for themselves and ‘he
child? Would it insulate the employer from
liability? Should fertility tests be required?
Will the right to privacy permit an employer
to inquire into the state of the reproductive
organs as well as the fertility and the mt ntions of the employee?
Could an employer refuse to hire a woman
who had a child every year for the past five
years but who says she intends to stop? How
far can an employer inquire into the
reproductive history of employees in light of
the righ* of privacy? 1 don’t know the
answers to these questions, and 1 dare say
no one does.
There is no doubt that not hiring or not plac
ing women into jobs involving (jxposure to
toxic substances is discriminatory because it
is a denial of equal employinenl oppor
tunity ‘But. th.it is not the question. This
IVOMI’K Al WORK
issue is whether such an exclusion is
prohibited discriminatory treatment under
the equal employment laws. Because there is
no precedent on this issue. I cannot say how
a court would rule. However, one thing the
analysis does tell us is that the issues cannot
be finally resolved in the courts unless the
courts reject the traditional and well-settled
concepts of tort liability. If the courts were to
abandon the existing principles in favor of a
new set of laws, they would be deciding
very difficult moral and social questions.
To me. the more appropriate forum for such
decision-making js the legislative forum. In
light of the problems outlined above, one
can envision special compensatory pro
grams such as a new category under
workers' compensation which compensates
those women who are denied employment
opportunity because of their potential role
as a mother. While this approach remedies
one aspect of the problem, it is not entirely
satisfactory because women are not assured
of full employment opportunity. They
would not be in positions to improve their
jobs because they would not be part of the
system. In addition, the exclusion of women
from particular jobs would cost a great deal
of money and would result in a loss ol
skilled workers from the workplace.
!
I
In conclusion, looking at the options given
above, the following alternatives are availa
ble:
First, the existing body of law could be ap
plied. and the test for discrimination would
be whether the excluded class was defined
as narrowly as possible. It should be noted
that the Title VII Guideline requiring that
pregnancy be treated a» a temporary dis
ability is presently being tested in the
Supreme Court case of General Electric v.
Gilbert* So the treatment of pregnancy as a
sex classification may be affected by the
court s ruling in that case, but the employer’s
tort liability would not be affected.
WOMES AT WORK
Second, the body of law could be changed
by judicial or legislative action. For exam
ple. women could be allowed to waive the
rights of the fetus within the employment
context. This change could be analogized to
the abortion decision which prevented a
state from regulating abortions in the earlier
months of pregnancy. However, such a
change would be dramatic and it must be
weighed against the possibilities of bringing
deformed children into the world.
Finally, society could recognize the risks in
volved in exposure to toxic substances and
could establish a system for compensating
women, and maybe eventually men. who
are denied employment opportunity. This
alternative, which accepts the first alterna
tive. provides relief to victims, and creates a
mode to define the affected class, requires
legislation.
I believe that the legislative forum is the
proper place for addressing the issues.
However, there appears to be no question
which can be adequately or finally resolved
until the scientists establish the facts on the
dangers present in the workplace. Then
hopefully, scientists will develop and
employers will adopt the technology neces
sary for assuring adequate protection for po
tential offspring.
The task before us*is to work toward assur
ing men and women of their rightful place
in the workplace while at the same time pro
tecting the health of future generations. It is
not an easy one, but we must begin to take
some steps. Conferences like this help to in
form us of the problems, but we can make
few decisions until we know the facts about
the hazards, and that information must
come from the scientists, not the lawyers.
The Supreme Court has issued an opinion in the Gilbert case, but
the question of whether pregnane) is a sex classification has not yet been
resolved.
154
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SPEAKERS AND MODERATORS
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Marvin L. Amdur, M.D.. Director
Buffalo Industrial Med. Ctr.
Buffalo. N.Y.
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Donald J. Billmaier, M.D.
Asst Medical Dir.
Owens-Corning Fiberglass Corp.
Toledo. OH
Harold R. Imbus, M.D., Sc.D.
Medical Director
Burlington Ind ’strier, Inc.
Greensboro, N.C.
Marcus M. Key. M.D.. Prof.
Occupational Health
Univ, of Texas
Houston. TX
J. Howard Bunn. Jr.. Chairman
Interdepartmental Task Force
on Workers’ Compensation
U.S. Department of Labor
Washington. D.C.
Marshall E. LaNier, Director
Div. of Technical Services
NIOSH
Cincinnati, OH
Ernest M. Dixon. M.D.
Corp Medical Dir.
Celanese Corp.
New York, N.Y.
Ludwig G. Lederer, M.D., Ph.D.
Corp. Medical Dir.
American Airlines
New York, N.Y.
Thomas S. Ely. M.D.
Asst. Dir.. Health. Safety, and
Human Factors Lab.
Eastman Kodak Co.
Rochester. N.Y.
John H. Lewis, J.D.
Attorney at Law
Coconut Grove. FL
Barbara Healy. R.N.
Supervisor. Nursing Service
Kodak Park
Eastman Kodak Co.
Rochester. N.Y.
William D. Hoskin. M.D.
Med. Dir.. Kodak Park Div.
Eastman Kodak Co.
Rochester, N.Y.
Vilma R. Hunt. A M.. Assoc. Prof.
Environmental Health
Penn. State Univ.
University Park, PA
Kathleen M. Lucas, J.D.
Off. of Solicitor, Div. of Labor
Relations and Civil Rights
U.S. Department of Labor
Washington. D.C.
David V. MacCollum. P.E.. C.S.P.
Pres., Amer. Society of
Safety Engineers
Sierra Vista. AZ
Sol M. Michaelson. D.V.M.
Dept, of Radiation Biology
& Biophysics
University of Rochester
Rochester. N.Y.
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155
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S. D. Steiner, M.D.
Former Medical Dir.
General Motors Corp.
Detroit. MI
Franklin A. Miller, Supervisor
Ind. Hygiene Sec., Health, Safety.
and Human Factors Lab.
Eastman Kodak Co.
Rochester. N.Y.
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Alexander L. Strasser. M.D.
Medical Dir.
Stromberg-Carlson Corp.
Pochester, N.Y.
Helen P. Onyett. R.N., B.S.
Occ. Health Consultant
Employers Ins. of Wausau
Indianapolis. IN
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Robert L. Wick. Jr., M.D.. Prof.
Department of Preventive Medicine
The Ohio State University
Columbus, OH
Nicholas A. Pace, M.D.
Medical Dir. of New York
Executive Offices
General Motors Corp.
New York, N.Y.
C. Craig Wright, M.D
Mgr./Med. & Health Services
Xerox Corp.
Rochester, N.Y.
J. Newell Stannard, M.S., Ph.D.
Prof. Emeritus. Radiation Biology
and Biophysics
University of Rochester
Rochester, N.Y.
5
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