Good day, everyone. My name is Namesha Kalia, and I will be reviewing the Occupational and Environmental Medicine Regulatory Compliance Lecture with you. I'm the Chief Medical Officer for General Electric, as well as a part-time assistant professor at the Johns Hopkins School of Medicine. Pleasure to be here. First and foremost, let's review the objectives of this lecture. The first is to review the scope and elements of selected OSHA standards, and I have a list of those in one of the upcoming slides. We're also going to review the scope and application of selected regulations, such as HIPAA, FEMLA, the ADA, and GINA. And then we're going to review key provisions of the workers' compensation regulations, including reviewing federal workers' compensation programs. There is a supplemental slide set at the end of this slide deck, and I highly encourage you all to look at that. That includes the EPA regulations, and those are very frequently tested. Since we'll be discussing exposures to employees, it's also good to understand some basic terminology. So let's start off with threshold limit values, or TLVs. These are guidelines that are established by the ACGIH, and they're not law. They were adopted by OSHA in 1968, and there have been many revisions, though OSHA standards may not be revised. Second is the biological exposure indicator, and that's when a substance is measured at a particular level that corresponds to a particular TLV, the BEI will be how much of the particular exposure can be measured within an organism. And then NIOSH has their RELs, their recommended exposure levels. These are used for really best practice as OSHA standards, especially if the OSHA standards are not revised, then many employers can use the NIOSH REL, but again, these are not law. So let's do our first practice question. Which of the following is a legally enforceable standard? The recommended exposure level, a wet bulb bulb temperature, a permissible exposure limit, or threshold value limit value. We know from the previous slide that choices A and D are not legal requirements, so those can be eliminated. We also know that a wet bulb bulb temperature is not a legally enforceable standard. So the answer here is C, permissible exposure limit, or the PEL. So the OSHA PEL is the legal limit of an exposure that an employee has to a chemical substance or a physical agent, such as high-level noise. The PEL is established by OSHA, and it's usually based on an eight-hour time-weighted average, or TWA. There are some that can also be a shorter time frame, and those are called STELs, or short-term exposure limits. Most OSHA PELs were issued shortly after the OSHA Act in 1970 and have not been updated since, and so that's why you have updated kind of recommendations by NIOSH, but the updated recommendations are just that. They're just recommendations. They're not legally enforceable. Only the OSHA PELs and RELs would be legally enforceable. So what makes up an OSHA standard? Let's go through the criteria. The first thing is the preamble or the purpose of the OSHA standard. Second is the exposure monitoring, or how an employer would go about actually doing the monitoring for the specific exposure. They could have scope including permissible exposure limits or short-term exposure limits, such as what we talked about on the last slide, based on the specific exposure. And then they have exposure controls that they would recommend, such as PPE, signage, hygiene, and we'll talk about these a little bit when we talk about the specific OSHA standards. And then they can also include medical surveillance, such as exams, what is required to be a part of the exam, and also the frequency of the medical surveillance exams, the biological monitoring that may need to be in place, and then medical removal processes and or physician opinion letters that may need to be included in order to be compliant for an employer. In this lecture, we will be reviewing select OSHA standards. First one is the general duty clause, followed by the HASCOM standard, right to know. Then we'll talk about occupational exposure to noise, as well as the injury and illness record keeping that's required by employers. And then we'll get into the agent-specific standards for asbestos, lead, benzene, lead-borne pathogens, and cadmium. Now, there are a lot of different types of exposures that an employee could be exposed to in their workplace. And where OSHA has no specific standard, then employers are still responsible for complying with OSHA's general duty clause. And what the general duty clause says is that an employer shall furnish a place of employment which is free from recognized hazards that are causing or are likely to cause death or serious physical harm to employees. OSHA also provides guidance on recording and reporting occupational injuries and illnesses, OSHA says that an injury is recordable if it's a new injury or illness and the event or exposure in the work environment is a discernible cause of the event or contributor to the injury or illness. Work exposure does not have to be the sole or predominant cause, it can be a contributory cause to it. And then general recording criteria for an event or exposure cause, it is recordable if there's any death by the injury or illness, if it causes days away from work, if there's any restricted work or transfer to a different department due to the injury or illness, if there's any medical treatment that's beyond first aid that's considered a recordable injury or illness, if there's any loss of consciousness it's considered a recordable event, or if there's significant injury or illness diagnosed by a physician or other licensed healthcare provider. Additional mandates are that all needle sticks and sharp injuries involving contamination by another person's blood or body fluid or infectious material to be considered recordable. And as I mentioned before, it doesn't have to be the sole contributor, but it can be a significant aggravation of a pre-existing injury or illness. So if an event or exposure in the work environment resulted in any of the following, which would otherwise not have been caused, then it would be considered recordable. These can include death, loss of consciousness, days away from days restricted or job transfer, or medical treatment that's beyond first aid. And then we're going to talk about the hearing loss standard threshold shift that can also be considered recordable if there is an STS. It's also good to know the reporting requirements and the time increments for those requirements. As of January 2015, all employers must report work-related fatalities within eight hours to OSHA, if it's directly work-related. All work-related inpatient hospitalizations, all amputations, and all losses of an eye must also be reported to OSHA within 24 hours if it's directly related to a work-related incident. Fatalities that occur within 30 days of a work-related incident must be reported to OSHA. So that means if it's directly work-related, it must be reported within eight hours. If the fatality occurs within 30 days of a work-related incident, that must also be reported to OSHA. And then inpatient hospitalizations, amputations, or loss of an eye, these incidences must be reported to OSHA only if they occur within 24 hours of a work-related incidence. The specific forms that are used to keep the log of incidences and injuries at work are the OSHA Form 300. This is a log of the work-related injuries and illnesses that occur. There's the OSHA Form 301. That's the injuries and illness incident report. And that's kept by the company. And if a representative, such as a union or an employee, asks for the OSHA 301 log, that must be provided. And the other one is the OSHA Form 300A. And that's a summary of the work-related injuries and illnesses. And this is usually updated annually. And it must be certified by the company and posted for a three-month period of the year following. Now, let's talk a little bit about the Hazardous Communication Standard. This standard says the chemical manufacturers, distributors, and importers must convey hazardous information to downstream employers by labels on containers and the safety data sheets, the SDSs. Employers must keep and maintain access to all SDSs. And these SDSs must be available to employees and any authorized representatives. So, that could be unions, that could be physicians, that could be emergency personnel that have to access a certain area. And then, there should also be a hazardous communication program in place that includes training on SDS and access to the SDSs. So, let's now move to talking about some agent-specific standards. And first, we'll talk about lead. So, this is Standard 1910.1025. And it applies to general industry. There is a separate one that covers construction. So, for this standard for lead, the action level is 30, 30 micrograms per meter cubed of inorganic lead over an eight-hour time weighted average. And so, at this level, the employer would be required to put in engineering controls and work practices to reduce exposure. And then, they might also implement some – they should also implement some personal hygiene practices, such as washing hands before eating and then taking showers before leaving the work site. And they may – should also be providing personal protective equipment and potentially take all engineering and administrative controls in order to reduce the exposure limit to employees. The PEL for lead is 50 micrograms per meter cubed of inorganic lead over an eight-hour for – eight-hour period for covered employees. There does need to be some biological monitoring and medical surveillance for all employees exposed to levels of inorganic lead above the action level for more than 30 days per year. And this standard also provides for medical removal protection for employees once they've reached a certain threshold of their lead levels. And employers must – and they're required to also maintain the worker's earning, seniority, and employment rights and benefits for a period of up to 18 months if they're on the medical protection program. The medical protection program also requires a physician's written opinion summarizing the findings. So, lead is a standard that's often asked about because it has this specific medical removal program that's somewhat unique to it. So, let's get into some of the details. So, there are multiple exams that are required for lead exposures. So, prior to the assignment, the employee would receive a history and physical examination, including a blood pressure. They would get a blood lead level and a zinc protoporphyrin level or ZPP level, a CBC, BUN, creatinine, urinalysis, and microalbumin. And that's really because of the way the lead accumulates in certain organs. And so, you're checking for baseline faculties of the different organs if the employee is going to have long-term exposure to lead at their workplace. And then every six months, they would continue to get a BLL and a ZPP. If the BLL is more than 40 in the past 12 months, then they would get an additional annual medical exam. And or as soon as possible, they would also be seen by a medical provider if they start to develop any signs or symptoms of lead poisoning. This could be high blood pressure. This could be joint or muscle or abdominal pain, memory or concentration issues, headaches, mood disorders, fatigue, or sleep disturbances. And or if they have any questions about the ability to procreate a healthy child, then they should be seen by a medical provider. And then a medical exam is also required when they're removed from the exposure. After the initial evaluation, they, as I mentioned before, get every six months, get a BLL and ZPP. And then every two months, if the BLL is greater than or equal to 40 until the employee has two consecutive samples that are below 40, they will, at least if they're part of the medical removal program, have at least monthly evaluations for elevated levels. And then any sampling that exceeds the level for the MRP, the employer must provide a second sample within two weeks to confirm that it is actually high after the worker receives notice of the first elevated sample. So what triggers the medical removal program? There's a few different criteria that could trigger it. One is that the blood lead level of 60 or greater, and that has to be confirmed by a second follow-up BLL within two weeks after the employee receives the results of the first BLL. The second criteria that could be met is that the average of the previous three BLLs or the average of all BLLs in the previous six months equals to or exceeds 50, unless the last blood sample is below 40, because then, again, that's permissible. And then the third criteria is when in a physician's judgment, continued exposure to the lead at the current job would pose a significant risk. So that could actually trigger a medical removal process as well. So the way I like to kind of remember the different numbers associated with lead is that 30 is the action level, 40 is what you want to make sure that your annual medical exam, that your BLL is less than 40, and 50, that's the Pell, and 60 is typically the medical removal program. So 30 action level, 40 medical exam threshold, 50 is the Pell, and 60 is the MRP program. So next, let's talk about the OSHA asbestos standard. And just like lead, there are two different standards, one for general industry and then one for construction. And this covers all employees who are exposed to at or above the TWA or the excursion limit. And the TWA for asbestos is 0.1 fiber per cc of air as an eight-hour average, and the excursion limit is one fiber per cc of air for 30 minutes. And as you may recall, asbestos fibers can, or asbestos-based material is resistant to heat and corrosive chemicals. So depending on the chemical compositions, fibers may range in texture from coarse to silky. And these fibers are widely used in industry because of their high tensile strength, their flexibility, their heat and chemical substances, and good frictional properties. So asbestos fibers primarily enter the body through inhalation or by ingestion. So those are typically the body systems that we'll focus on when we do the exams as well. So the frequency of exams for asbestos are one is pre-placement, and then one is periodic, annually. And then one is a termination if there hasn't been an exam in the past year. So, and the contents are specific to asbestos. So you have a medical and work history of where the exposures may occur at work, and then predisposing symptoms, especially of underlying lung disease or smoking history. Complete physical exam with emphasis on the respiratory system, cardiovascular system, and digestive tract. The contents must also include completion of the respiratory disease standardized questionnaire in Appendix D of the OSHA standard. It must contain a chest radiograph with a B interpretation. And then PFTs are also to be included, and that must have the FVC, or the forced vital capacity, and the forced expiratory volume at one second, or the FEV1. This is a chart that goes to the frequency of chest imaging that's required for workers that are exposed to asbestos for general industry. So you can take a look at the age of the employee, and then you can also take a look at the years of exposure that employee may have had since their first exposure. So whether it's zero to 10 years, they're early on in their exposure history, or if it's 10 plus years, how often they'd be required to get chest imaging. For asbestos, the medical written opinion has certain components that must be met. So one is the results of any examinations that were conducted for the physical exam or any lab examinations that were given. The second is the MD's opinion as to whether the employee has any detected medical conditions that would place them at increased risk of impairment from exposure to asbestos. The second would be any limitations on the employee or upon the use of the PPE, such as clothing or respirators that the employee might be required to use. Fourth is a statement that the employee has been informed by the physician of the results of the exam and medical conditions resulting from asbestos exposure that required further explanation or treatment. And lastly, a statement that the employee has been informed by the physician of the increased risk attributable to the combined effect, especially of smoking and asbestos exposure when it comes to lung cancers, especially mesothelioma. It's been estimated that 60 to 80 percent of asbestos workers may be smokers. And so this is really important for the physician to explain to the employee and really encourage smoking cessation so that they're not at higher risk of lung cancers, especially mesothelioma. We're going to cover the OSHA benzene standard, and this covers workers that are exposed to the action level of 0.5 parts per million times 30 days per year, or the PEL of one part per million over an eight-hour shift times 10 days for the year. The STEL for benzene is five parts per million over a 15-minute sample. And that's important because even at short-term exposure limits to high levels of benzene, you can still get symptoms of drowsiness, dizziness, unconsciousness, and even death. The benzene standard does have an initial as well as annual exams. It has emergency exams, exit exams that are required, and then a medical referral to a hematologist and a medical removal program for up to six months for workers with abnormal hematology that may result from the exposure to benzene. The routes of exposure for benzene are primarily inhalation and eye or skin contact and or ingestion. As far as medical surveillance exams for benzene, there does need to be a history and physical exam including a respirator clearance, and that specifies that it has to have PFTs for workers who will be wearing respirators for more than 30 days per year. Labs are also required including a CBC with DIF, platelet count, and RBC indices. If there's an emergency exam that's required for a worker that has had an exposure and may be displaying some symptomatology, then you would do a urine phenol at the end of the shift. And it's very unique and important to remember for potential benzene exposure. So urine phenol at the end of the shift. If the urine phenol level is greater than or equal to 75 milligrams or phenol per liter of urine, then you would obtain a CBC with DIF platelet count every three months. And an MD written opinion is required for benzene as well. Next, we'll talk about the OSHA blood-borne pathogen standard, which requires that employers identify workers with potential exposures to blood-borne pathogens and then also require free of charge to hepatitis B vaccination to any employee that may be exposed. If an employee has had previous vaccination or a previous infection, then titers must also be free to employees. The standard also requires a declination to be sent by employees if the vaccination is declined. And it requires provision of post-exposure evaluation for CDC and USPHS guidance. The next agent-specific standard is cadmium. So cadmium and its components are highly toxic and exposures to the metal are known to cause cancer and targets bodies, cardiovascular system, renal system, GI, neurological, reproductive, and respiratory systems. And as we hear more and more about the rechargeable batteries, the nickel cadmium rechargeable batteries, we are seeing a lot of cadmium exposure in workers as well. The China, South Korea, and Japan are the leading producers of cadmium in the world, but the US is number four. So the cadmium standard workers that are exposed to five micrograms per meter cubed as an eight-hour TWA for 30 days per year would be included in that. This does include a pre-placement evaluation that it has a chest x-ray and PFTs and respiratory clearance as a part of it. Periodic exams include biological monitoring for blood and urine cadmium levels, the BUN creatinine, urinalysis, CBC, and serum beta-2 microglobulin that are monitored. There are emergency and termination exams that are part of the standards. And then blood and urine, cadmium, BUN, creatinine, UA, CBC, and serum beta-2 microglobulin are monitored. And there is also a medical removal program that's a part of the cadmium standard. So switching gears a little bit, let's talk about HIPAA, or the Health Insurance Portability and Accountability Act. And really the main questions you're gonna get is what are the exceptions to HIPAA? So let's talk about some of those. So they're primarily covering public health activities and workers' compensation as the two exceptions. So covered entities may disclose protected health information to public health authorities that are authorized by law to collect or receive information for preventing, controlling diseases, injuries, or disabilities, or individuals who have been contracted or been exposed to communicable diseases when notification is authorized by law, or employers regarding employees when required by employers for information concerning work-related injuries or illnesses in the workplace related to medical surveillance, because such information is needed by the employer to comply with OSHA regulations, with MSHA regulations, or similar state laws. And then workers' compensation is also not covered under HIPAA. Covered entities may disclose protected health information to comply with workers' compensation laws and other similar programs providing benefits for work-related illnesses or injuries. So I think those are the main important points to remember about HIPAA. So now let's test your knowledge with a practice question. So per HIPAA, which of the following are you prohibited from disclosing to others without the patient's permission? A is a new diagnosis of active tuberculosis. Well, that would be a communicable disease, so that is not covered by HIPAA. So it's not A. Let's go to the other, pregnancy. That's like maybe the answer. C is asbestosis due to occupational exposure to asbestos. Now that's a work-related injury or illness, so that is not covered under HIPAA. And then, so C is not the answer. And then it's ankle fracture due to a fall at work. So again, that's a work-related injury, so that would not be covered. So B would be the correct answer here. Next, let's talk a little bit about FEMLA, or the Family and Medical Leave Act, and who are the covered employers for FEMLA. These are private sector employers that have 50 or more employees. It doesn't have to be all in one location, but it has to be a location where the employer has 50 employees within a 75-mile radius. It also covers public, state, and federal sectors of any size school, and it covers all employees there. And then in order to be a covered employee, you have to be employed by your employer for 12 months and 1,250 hours of service during that 12 months, the previous 12 months. So what are the FEMLA entitlements? You are able to get 12 weeks of unpaid leave with job preservation with equal pay and benefits for the care of one of the few criteria. One is either the birth of a son or daughter or placement of a son or daughter with the employee for adoption or foster care. Secondly, it could be to take care of a spouse, son, daughter, or parent with who has serious health condition. Thirdly, it could be for a serious health condition of your own that makes the employee unable to perform the essential functions of his or her job. Or lastly, it could be for any qualifying extingency arising from the fact that a spouse, son, daughter, or parent is a military member on covered active duty or called to covered active duty status. And this leave can be taken intermittently. It does not have to be taken all at once. And now we're gonna talk about the Americans with Disabilities Act or the ADA of 1990, and then the 2008 amendment. So this applies to all employers with 15 or more employees and prohibits employment discrimination against a qualified person with a disability or who is regarded as having a disability. So again, the emphasis is that they do have to be qualified in the first place. They must have the necessary knowledge, skills, and abilities to perform the essential functions of the job. Caveats to this form of drug abusers are covered. Current drug abusers are not covered. And it does prohibit pre-offer medical examinations of which drug testing is not considered a medical examination per the ADA. It also requires that employers actually define what the essential functions of the job are. And this is primarily so you can understand if somebody is qualified or not to do the essential functions of the job. And they must also offer reasonable accommodations to enhance employability of qualified persons. So who qualifies as being disabled? It's a person with an impairment that substantially limits their major life activities such as seeing, hearing, speaking, walking, breathing, performing manual tasks, learning, caring for oneself, and working. In 2008, this list was also expanded to the definition of what a major life activity could be by two non-exhaustive lists. The first list included many activities that the EEOC has recognized such as walking as well as other activities that are not specifically recognized such as reading, bending over, communicating. And the second list includes major bodily functions such as functions of the immune system, normal cell growth, digestive, bowel, bladder, neurological, brain, respiratory, circulatory, endocrine, and reproductive functions. So quite an exhaustive list. The 2008 amendment of the ADA also states that mitigating measures other than ordinary sunglasses or contact lenses shall not be considered in assessing whether an individual has a disability. And it also clarifies that an impairment that is episodic or in remission is a disability if it would substantially limit the major life activity when it becomes active. So let's test our knowledge with a practice question or a case. So an otherwise qualified 35-year-old woman is offered a position as an administrator with duties including attendance at frequent team meetings. The hospital's admin building is a historic building with no elevators. There are 20 steps between each floor. Traditionally, new administrators have offices on the third floor of the admin building where senior workers are located on the first floor near the meeting rooms. The newly hired woman has a congenital hip dysplasia and states that she cannot climb stairs. So what would be a reasonable accommodation for this woman? So reasonable accommodations may include finding her another office space on the first floor that could accommodate her. Another potentially reasonable accommodation depending on the, would be to think about placing an elevator in the building, not just for her, for other employees as well that might have other conditions. The second option that was mentioned would be a lot more costly. But in general, most accommodations typically cost employers less than $500 according to research. And most companies cannot claim inability to accommodate employees. Most large companies are not able to claim that. But they may claim a business necessity. So if you have an employee, for example, that has a disability but they can't get to work until a certain time because of frequent medical visits, the employer can claim that it's a business necessity that the shop open at a certain time and therefore they cannot accommodate the request. A useful resource that I found is provided in the slide. And also as a part of the ADA, what can an employer ask or not ask? So let's see, prior to the job offer, an employer may not ask the job applicant to answer medical questions or take a medical exam. When the employee has a conditional job offer, an employer may ask a job applicant whether or not they can perform the job and how they would perform the job. The law also allows an employer to condition a job offer on the applicant answering certain medical questions or successfully passing a medical exam, but only if all new employees in that same job have to answer those questions or take the exam. So they can't single out employees, but if a certain department is on a whole given the same kind of questionnaire or required to pass a medical examination, for example, to test their strength, because there'll be lifting a lot in that job, then that is allowed. After hire, an employer can generally ask only medical questions that require a medical exam if the employer needs documentation to support an accommodation request, or if the employer believes that the employee would not be able to perform the job successfully or safely because of a medical condition. Again, let's test our knowledge with the practice question. So which of the following may not be included on a post-offer physical intake form? The list your hospitalizations, as long as the entire department's being asked the same general questions, this is allowed. Number two, list your past surgeries. Again, this is allowed to be asked. C, do you have a family history of heart disease or stroke before the age of 50? That is not allowed. And then D, list your current medications. That, as long as the same question is being asked of personal medical history for a potential employee that's been given a conditional job offer that is allowed to be asked. So C is the correct answer here. You cannot ask about the family history of an employee. And that last question highlights why we're not, as employers, we're not allowed to ask these questions. And that's because the Genetic Information Non-Discrimination Act of 2008, or it's also called GINA, which prohibits health insurers or health plan administrators from requesting or requiring genetic information of an individual or the individual's family members or using it for decisions regarding coverage, rates, or pre-existing conditions. It also prohibits most employers from using genetic information for hiring, firing, or promotion decisions and for decisions regarding terms of employment. So how does GINA impact OEM practice? Well, family history cannot be included on forms for physicals. Personal history of genetic illness may not be used for purposes of certification for fitness for duty. Protected data that is considered as a part of a health risk assessment should not be available to the employer. Aggregate data can be, but personal data cannot. As usual, medical records should not be maintained by HR or any non-medical department or staff. And you always wanna consult the hospital legal or an attorney for legal advice regarding any of these matters. So now let's switch gears a little bit and talk about workers' compensation. Workers' compensation is a no-fault state-administered program for provision of medical care and wage replacement, partial wage replacement typically, for occupational injuries and illnesses. Now, workers' compensation laws and practices vary state by state, but in general, benefits begin after three to five day waiting period after the injury or it's been reported. The requirements for reporting, provider selection, and benefits may vary. And again, it's state by state. And employers may be self-insured or they might have a covering insurer. And third-party administrators often administer these programs, so the case managers may be a part of a larger TPA that actually administers the day-to-day of the program. Federal workers are covered by the Federal Employee Compensation Authority administered by the Office of the Workers' Compensation Program. So when you're talking about workers' compensation disability or injuries, they're categorized into different categories. So you can have an injury that's considered temporary partial disability. So an example of this would be a fractured arm. So when you have this, many employers will have a light-duty pool or light-duty program. So if you can offer that employee with a fractured arm a temporary light or alternative duty program, this can reduce costs to the employer and also not have any lapses in employment for the employee. So the second category is temporary total disability. So this really comes into play if you have trauma with a head injury, for example, or injury in a policeman or a firefighter, and in certain jobs or certain departments, you may not have light duty at all. So they're either all or none. They're able to work all of the essential job functions that they were hired for, or there's no light-duty program for them. So they'd be considered a temporary total disability at the time as they're recovering. The third category is a permanent partial disability. So this would be like an amputation of an arm or hearing loss, something that's not gonna be coming back. And the employee might be receiving a scheduled reward or a lump sum payment because of the injury or illness that occurred. The last one is a permanent total disability. So this would be an employee who would have severe issues trying to come back to work, example, to be a severe spine or head injury. And there may be some potential for voc rehab, but sometimes there's not. And so this employee would be considered a permanent total disability case. Additional Federal Workers' Comp laws to be aware of are the Federal Employers' Liability Act. This compensates railroad workers injured on the job. The Jones Act or the Merchant Marine Act. This covers American workers that are injured at sea or seamen. And then there's a Longshore and Harbor Workers' Compensation Act, which covers the land-based maritime employees. The next set of slides covers EPA regulations that are often tested on board examination. First one we're gonna talk about is NEPA, which is the National Environmental Policy Act with amendments. This was established a national policy for the environment provided the establishment of a council on environmental quality. So prior to NEPA, federal agencies were more mission oriented. So an example would be to select highway routes to the shortest distance between two particular points, but NEPA was necessary to take a look at the environmental impact of the proposed plans instead. So it was the first comprehensive environmental law at the federal level, and it does require an environmental impact statement as a part of the law. Next is FIFRA, which is the Federal Insecticide, Fungicide, and Rhodeticide Act of 1972. So FIFRA established a set of pesticide regulations and the pesticide regulations are not only done after a period of data collection to determine the effectiveness of its intended use, but also the appropriate dosages and the hazards of the pesticide materials. So when it's registered and it is required for producers of pesticides to register with the EPA, a label is created to instruct the final user on the proper usage of the material. If the instructions are ignored, then the user is liable for any negative consequences that may occur. Only a few pesticides are actually available to the general public. Most are for commercial use and considered too dangerous for general use. So FIFRA also established a system of examination and certification for both private and commercial applications who is to purchase the pesticides. And then the distribution of the restricted pesticides are also monitored under this act. Next is TSCA, or the Toxic Substances Controlled Act, but under the EPA of 1976. And this regulates chemicals that are currently in existence that may be imminently hazardous. And it also prevents new chemicals that present an unreasonable risk of injury or health to the environment from entering the market. It requires manufacturers to report the content, the use, the health and environmental effects of the chemicals. And then important to know in 1986, the Asbestos Hazard Emergency Response Act, or AHERA, under the TSCA, was an amendment that covers the asbestos abatement in schools. The exemptions from TSCA are pesticides, as we talked about before, that's regulated by the FIFRA Act, tobacco and tobacco products, nuclear materials, that goes under the Atomic Energy Act, food, food additives, drugs, cosmetics, and devices, that's under the FDA, firearms and ammunition, that's Bureau of Alcohol, Tobacco, and Firearms, meat and meat products, that's the Meat Inspection Act, poultry and poultry products, which is the Poultry Products Inspection Act, and eggs and egg products, which is the Egg Products Inspection Act. So next, we want to learn about the air quality regulations, including the Clean Air Act of 1970, under the EPA, and that is what has set forth a list of six criteria pollutants under the National Ambient Air Quality Standards. These six criteria pollutants are carbon monoxide, lead, nitrogen dioxide, ozone, sulfur dioxide, and particulate matter, PM10 and PM2.5. There are primary standards, the primary standards are set to protect public health, but they basically are looking primarily at the health of sensitive populations, such as asthmatics, children, and the elderly, and there's also a set of secondary standards, and the secondary standards are to promote public health for and protect public welfare, but include the protection against decreased visibility, damage to animals, crops, vegetation, and buildings. Important to note also are the water quality regulations. First is the Clean Water Act of 1972, by the EPA. This only applies to recreational waters, not drinking water, but there is the Safe Drinking Water Act or SDWA of 1974, also under the EPA, and this applies only to treated water, not private wells. Private wells are managed by the private citizens who own them only. So the Safe Drinking Water Act does not cover private wells. The Safe Drinking Water Act sets forth maximum contaminant levels under the National Primary Drinking Water Standards, and this is the act that was responsible for outlining the use of lead pipes. It was also updated in 1996. Then there's also the U.S. Preventative Health Services Drinking Water Standards, which were first implemented in 1914. Regarding wastewater treatment legislation, there's the Clean Water Act of 1972. Again, we talked about this in the previous slide, but this is for recreational waters only, not for drinking water, and this is the act that established point source effluent standards. This is a certain level of discharge reduction that can be achieved by best available technology, and so that's covered under this particular act. And then it requires permits for all discharges, and this act also established priority pollutants. Those are a set of chemicals that the EPA regulates and that the EPA has published analytical test methods for. Next we have the Safe Drinking Water Act of 1974 under the EPA. The exception to this, again, is private wells or wells that serve less than 25 people. There were multiple amendments to this. In 1996, there was one that specified maximum contaminant levels for agents, and also requires public notification of violations by water suppliers. It's also important to know which agencies pass certain acts, so we'll go over those a little bit in this slide. So the USDA Food and Safety Inspection Services passed the Federal Meat Inspection Act, the Poultry Products Inspection Act, and the Eggs Product Inspection Act. Pasteurized Graded Milk Ordinance was by the US Public Health Services in 1924, and the FDA amendments are, one is the Miller Amendment of 1974, and that looked at pesticides more broadly when it came to food, their use in food, drugs, and cosmetics. And then the Food Additives Amendment of 1954, 58, I'm sorry, is important because it generally recognizes the safe additives exemption. And then also in 1996, the Food Quality Protection Act upgraded regulation of pesticides to the standard of no harm for all pesticides that are used on foods, and also updated regulations of carcinogenics. We talked about the NEPA Act of 1970s. This required the Environmental Impact Statements and was the first legislation to do so. It requires the review of short and long-term benefits of those environmental impacts, and then requires a list of resources that may be depleted by a certain regulation passing. And then there's the Marine Protection Research and Sanctuaries Act by the EPA of 1972, and that prevents ocean dumping if there's adverse effects to human or marine life. RCRA is the next one, or the Resource Conservation and Recovery Act. This is an important one. It was created to really address the increasing problem that our nation faced from our growing volume of municipal and industrial waste. It gives the EPA the authority to control hazardous waste from cradle to grave, and this includes the generation of, the transportation of, treatment of, storage, and disposable of hazardous waste. RCRA also sets forth a framework for the management of non-hazardous solid waste as well. CERCLA is the Comprehensive Environmental Response, Compensation, and Liabilities Act. This provides a federal super fund to clean up uncontrolled or abandoned hazardous waste sites as well as accidents or spills and other emergency releases of pollutants and contaminants into the environment. Through CERCLA, the EPA was also given power to seek out those parties that were responsible for any release and assure that their cooperation was in the cleanup. So that was really important. Next we have SARA, which is the Superfund Amendments and Reauthorization Act of 1986. This reauthorized CERCLA to continue cleanup activities around the country. Several site-specific amendments, definition clarifications, and technical requirements were added to the legislation, including additional enforcement authorities for those that were responsible for the hazardous waste dumpage in the first place. Also, Title III of SARA authorized the Emergency Planning and Communities Right-to-Know Act. That's really important to know for the examination. SARA mandates that every facility using, storing, manufacturing hazardous chemicals make public its inventory and report every release of a hazardous chemical to public officials and health personnel. Every facility must also cooperate with the physicians who are treating victims of the exposure. So that's all under SARA. We are at the end of our lecture, so I want to thank you for your time. Now welcome to our lecture entitled Occupational and Environmental Health Services Administration and System-Based Practice. I am Dr. Namesha Kalia, and I'm the Chief Medical Officer at GE, and I'm also Assistant Professor of Medicine in the Department of Medicine at Johns Hopkins. The objectives of this lecture will be to discuss the components and key programs, including the heritage conservation programs and ergonomics, review the elements and key guidance pertaining to commercial driver's medical examinations, review the prevalence of substance abuse in the workplace, interview the scope and practice of a medical review officer, and then also discuss the epidemiology of workplace violence. Most of you that practice occupational and environmental medicine know this already, but this is the management scope of an OEHS program, and you can read this slide on your own, but it basically highlights and summarizes what most chief medical officers or most occupational medicine practitioners are doing for employers. Part of our scope is medical surveillance programs for appropriate toxic cancer exposures, and the purpose of them is to identify toxic and specific early biological effects and hopefully be able to mitigate some of those effects or remove employees from exposure. Secondly, to provide data for group data analysis to monitor those hazards in conjunction with training to ensure appropriate use of PPE and to ensure there's fitness for duty. There's also different types of medical surveillance exams. There's post-offer, pre-qualification, periodic ones, emergency, or at request, and then there's exit examination. We went through this in my previous lecture, and the example components of medical surveillance programs for asbestos, for example, you have pulmonary function tests, radiographs, and physical exams that might be a requirement. For lead, you have blood lead levels, ZPP, and physical exam. For hearing conservations, you have audiograms that you must follow over time, and then there are special provisions for certain exams. There might be a physician written opinion that's required, for example, with asbestos, with lead, with blood borne pathogen standard, and there might be work removal programs as well, such as what we have with cadmium and lead. For certain professions, there might be an initial certification that's required, and that's employer-specific standards, such as the National Fire Protection Association, the NFPA 1582 for firefighters. OSHA may have certain standards for general duty and then also for construction, and then the FMCSA has regulations for DOT drivers. There's also return-to-work examinations, so there's post-occupational injuries or illness examinations. There's also post-personal injury or illness examinations that may be a part of an employer's return-to-work program. So, let's define an impairment versus a disability. An impairment is a decrement in function or loss of a body part or organ system, whereas a disability is a decreased capacity of an individual to meet their personal, occupational, or societal demands as a consequence of that particular impairment. So, why this is important to understand the definitions is that a person may be impaired but not disabled relative to their occupation. So, for example, a paraplegic in a teacher versus – or even a physician versus a paraplegic in an athlete. So, in one instance, you have a paraplegic who would not – as a teacher, they're not disabled relative to their occupation, whereas an athlete would be disabled as well as impaired relative to their occupation. And then, similarly, let's talk about limitations versus restrictions. So, limitations are described what a person cannot do for lack of physical or functional capacity, whereas a restriction is something that is determined that somebody should not be doing due to lack of function for safety reasons. So, for example, a person with Meniere's disease may have a limitation of balance and then support the restrictions, which include no work at heights. Now, there are multiple tools that an employer may have to determine what an employee is or is not able to do, and one of them is a functional capacity evaluation. The applications for this are sometimes used for – FCEs are used to return to work post-injury or rehab, or they might be used for an impairment evaluation. There are some issues with FCEs. They often measure a worker's minimal rather than maximal functional capacity, and they're very effort-dependent on the employee, and they're also very experience-dependent on the examiner's end. There are multiple models that are also available, so it's not a standardized process that you can wholly rely on to determine what an employee is or is not able to do. You do need to ensure that a quality assessment is done, and there's consistency between the assessments that you're doing. Also, not just the evaluators from the evaluator's perspective, but also from the employee's perspective because a worker can consistently underperform as well. So, we're going to switch gears a little bit and talk about the Hearing Conservation Program by OSHA, which is 1910.95. So, parts of this program include noise measurements and how they're taken, engineering noise controls within a workplace, audiometric testing of the employees and hearing protection that's provided for the employees, employee training and education, as well as record-keeping and program evaluation. When it comes to measuring noise, there are multiple different types of tools that can be used. There can be personal monitoring or noise dosimeters that can be used. There's area-level monitoring, so sound-level meters that can be used, and then employers can also look at noise maps within a certain factory setting or industrial setting to know where the noise is at its highest decibel levels, and there's also octave band analysis that can be done. As far as noise exposure measurements, the measurements are in decibels on an A-weighted scale, and an A-weighted scale is used because that's what corresponds to human hearing frequencies. The OSHA action level for noise is 85 decibels, and at that level, a Hearing Conservation Program, including audiograms, is required by employers. The OSHA PEL for noise is 90 decibels. So, sometimes within a workplace, you can have extremely high noise levels for a set amount of time, and so there is an exchange rate that can be used to calculate the amount of exposure to noise an employee has. So, exposure time must be half for every increase of five decibels in noise levels. So, remember, we started off with the 90 decibel for the OSHA PEL for an eight-hour period. So, if the 90 goes up to 95 decibels, then that employee should only be able to be exposed to that for four hours. Moving on, if you move up to 100 decibels, then they should only be exposed to that for no more than two hours, et cetera, et cetera. So, once you get up to 115 decibels, now you're reaching the short-term exposure limit, and so 15-minute maximum permissible exposure of 115 decibel is the regulation by OSHA. As far as hearing protection devices, employers provide hearing protection devices to those exposed at 90 decibels on an eight-hour time-weighted average at no cost to the employee, and they are to be replaced as necessary. An employer should also provide double protection if the noise level exceeds 110 decibels, but remember, the noise level has to be less than 115 decibels because that is the STEL. Employers also need to ensure that these are worn by employees as required, especially those who have not had a baseline audiometry, and the hearing protection devices are worn at 85 decibels if there is a standard threshold shift or a transient threshold shift that's been detected on the audio brain. Now, when an employer offers hearing protective devices, there is a correction factor that can be used to estimate what the real-world noise reduction rating actually is. So, when you're looking at ear muffs, this is the calculation that you use to actually estimate the true amount of exposure that an employee has. It's 0.75 times the NRR, which is the manufacturer's noise reduction rating, minus seven. When you're using foam plugs, the calculation is 0.5 times NRR minus seven, and then all other plugs are 0.3 times NRR minus seven. So, essentially, what you know from this calculation is ear muffs are probably the best protective device there is, but there's still a correction factor from what the manufacturer typically reports in real-world protection to the ears for employees. So, now let's test our knowledge with a practice question. So, ambient noise around a grinder machine located on a plant floor is measured at 110 decibels throughout the work shift. The most effective method of controlling worker exposure to this hazard is A, implementation of a policy requiring foam ear plugs, okay, B, implementation of a policy requiring the use of foam ear plugs, okay, enclosure of the grinder, or replacement of the grinder with a quieter machine. So, this question is actually asking more about the hierarchy of controls than it is about noise, and so the replacement of the grinder with a quieter machine or substitution or elimination of the hazard itself is the right answer. And there are real-world consequences to chronic noise exposure. So, you can have chronic noise induced hearing loss, and the National Institute of Occupational Safety and Health, the NIOSH, estimates that for excess risk of hearing impairment per working lifetime is 8 percent excess risk if you're working at noise levels of 85 decibels for the mean daily noise level, and it goes up to 25 percent when that mean exposure increases to 90 decibels. With noise-induced hearing loss, the early impairment occurs at the 4,000 hertz mark on the audiogram with the higher frequencies relatively spared. When you contrast that with presbycusis or age-induced hearing loss, the deficit deepens at the higher frequencies, and I have a couple of audiograms that we can look at in the upcoming slides that can show that. And it's clinically noticeable when thresholds are in the speech range, which is about 500 to 3,000 hertz. So, let's quickly review the transmission of sound to the inner ear, going back to med school a little bit. So, as you can remember, it goes from the external canal to the tympanic membrane to the ossicles, then through the oval window, and then to the cochlea, and that's where we see the hair cells. And so, when we look at the pathophysiology of noise-induced hearing loss, it affects the transduction of vibration to nerve impulses in the organ of Corti or the cochlea. So, the hair cells, again, rest on the frequency-based basilar membrane, and each point along the the membrane has a specific frequency that matches to it. So, the movement of the cilia creates the chemical neural signals, and in noise-induced hearing loss, most of it's seen at the 4,000-hertz high-frequency area of the cochlea at the basilar turn. So, let's take a look at a couple of the pictures on the next slide. This is a picture of the cochlea and the hair cells that can be seen along the basilar membrane of it. So, when you are looking at the oval window, the frequency that corresponds to that is about 20,000 hertz, and then when you get all the way down to the apex, where the H is, that's where the frequency that corresponds to it is about 200 hertz. So, what I was referring to at the basilar turn is where this arrow is, and that's around where the 4,000-hertz frequency is corresponding to. So, this is that same cochlea that we're looking at, but you can see that the hair cells have been damaged. So, exposure to regular and long-lasting noise damage damages the sensitive hair cells on the cochlea. This can result in permanent noise-induced hearing loss. It can also result in tinnitus, buzzing, or ringing noise that originates in the person's ear. These tiny hair cells cannot be repaired or replaced, so once they're damaged or destroyed, it's permanent. And this is what you see on the audiogram. So, the solid line represents typical audiogram of early noise-induced hearing loss, so you see the most remarkable dip around the 4,000-hertz region, and compare that with presbycusis, and that's the dashed line, where you see a gradual decline, but it's not sparing the higher frequencies. And in this audiogram, going from top to bottom, you can kind of see an audiogram showing the combined effects of noise and age. So, you see the dip at the 4,000-hertz, but then you also start to see decreases in the higher frequency. So, what can happen when you're exposed to a lot of noise is you can develop a temporary threshold shift, and that occurs when there's a transient diminished acuity following overexposure to noise. It can last for minutes to hours to several days, and then there's a resetting period after some period of quiet or rest. There usually is a return to baseline, and that's what sets the temporary threshold shift apart from the standard threshold shift, which we'll talk about next. So, a standard threshold shift occurs when there's a 10-decibel average shift from baseline at the 2, 3, and 4-kilohertz ranges. So, you look at those ranges in specific. Again, this is a permanent shift. So, if there is a change in the 2, 3, and 4-kilohertz ranges, then you do a 14-hour noise-free retest within 30 days to see if this persists, and you get a repeat result. If it persists, there's written notification and counseling, and then you have to revise the baseline because this is now the employee's new baseline. This also becomes an OSHA log recordable if there's an STS and the overall mean hearing level at the 2, 3, and 4-kilohertz is greater than 25 decibels. Okay, so now let's switch gears and cover the topic of ergonomics. We'll talk about the evaluation, specific hazards, and intervention and controls, such as NIOSH sit-stand workstations, lifting devices, overhead-mounted tools, and then workstation redesign. So, ergonomic hazards occur when there's repetition, static exertion, forced localized contact and pressure, posture that's incorrect, vibration, or temperature, especially cold. Ergonomic evaluations consist of basic information to consider, like the purpose of the job and the outcome of the actual task that you're trying to accomplish, the task description, production standards, like quantity and quality that may need to be tweaked in order to optimize or decrease the risk for the employee, work objects that are used, and if those could be modified slightly, the tools and equipment, the workstation evaluation, the methods that are being used, and the actual environment, the heat and cold stressors. Musculoskeletal disorders that are associated with ergonomic stressors, there are a few. So, upper extremity work-related musculoskeletal disorders that include carpal tunnel and cupidal tunnel, lifting-related healthcare workers, musculoskeletal disorders, as well as hand-arm vibration syndrome, or HAVS. This is frequently tested on the board. So, it's also known as vibration white fingers or occupational Raynaud's, and it's a vasospastic and neuropathic symptoms from prolonged exposure to vibration tools. Examples of some ergonomic controls that, when we're looking at the hierarchy of controls, engineering controls would be vibration-reduced seatings and tools, like you've seen in buses, probably ceiling-mounted tools, workstation redesigns, and then overhead hoists for patients. Administrative controls that can also help with ergonomics are work rotation from repetitive tasks, restriction during cold temperature, and lifting teams in healthcare settings. And then PPE that can be used are vibration-dampening tools and gloves. So, NIOSH has a lifting equation, and what it does is it takes a specific load constant or baseline weight of 23 kilograms, 51 pounds, and that load constant is adjusted to a recommended weight limit by multiplying it by several different factors. So, the recommended weight limit is defined by NIOSH as the weight of a load that nearly all healthy workers could perform under a substantial period of time, so up to eight hours, without the increased risk of developing lifting-related lower back pain. And then, under ideal conditions, the RWL is safe for 75 percent of females and 90 percent of males. Let's take a look at the NIOSH lifting equation in detail, and remember, we are trying to come up with the RWL based on this equation. So, we start off with the load constant, and then we have a horizontal multiplier. So, that's the horizontal distance of the load is lifted, and that's the distance of the hands from the midpoint between the ankles. Then you have the vertical multiplier, and that's the starting height of the hands from the ground. Then you have the vertical distance of lifting, so it's a distance multiplier. And then the next one is the frequency multiplier, and that's the time between lifts or the frequency of lifting. Next, you have the asymmetric multiplier, and that's the angle of the load in relation to the body, so straight in front of you or off to the side, so is there any twisting involved? And then you have the coupling multiplier, and that's really the grip, the quality of the grip or the hand hold, based on the type of handles that are available, like, so it's the coupling of the hands and the grip. So, once you've calculated the RWL, the goal is to come up with a lifting index. This lifting index estimates the amount of physical stress that's required with this lifting task. So, it can be calculated once you have that RWL, and the way you calculate it is a load index is a load weight divided by the RWL that you just calculated. And if the lifting index is greater than one, then this is a stressful event. So, anytime you're over one, you want to try to see which variables can be modified to get that LI or the lifting index to less than one to prevent risk for low back injury. Switching gears a little bit, this slide just is talking about the different DOT agencies. For DOT specifically, there is a National Registry of Certified Medical Examiners, and in order to become a certified medical examiner, you do have to do the required training and pass a certification exam. And there are also requirements for reporting that come along with becoming a certified medical examiner for DOT. So, if you are a certified medical examiner for DOT, the main question that you're asking yourself and reminding yourself is the essential job functions that come along with being a commercial driver and if the commercial driver is going to be able to safely operate the vehicle. So, that includes operation of the actual motor vehicle itself, so it includes the sensory awareness, intact vision and hearing, and sensory motor ability to safely control the vehicle. And then remember the driver also has to do safety checks of the vehicle, so including the lift gate, ensuring cargo integrity is intact, the wheelbases, tires, and attachment of trailers to the cab, including the ability to bend and stoop and climb in and out of the cab itself. So their job may also include loading and unloading of cargo and covering the cargo with tarp, and alertness for long periods of time, and tolerance of irregular work and meal schedules. So in order to assess an individual's ability to do those tasks, there are components of the DOT exam that are standardized. One is the self-reported history and medications and reviewed by the examiner. There's a vision test which includes the acuity, visual fields, and color vision, red, yellow, green. And there's also a hearing or whisper test or audiogram, and they can wear their hearing aid during this. You also check their blood pressure, their pulse, their height and weight, and calculate a BMI. You do a urine dip for specific gravity, protein, sugar, and blood. You do a physical exam, a thorough physical exam, and any additional testing or records as determined by the medical examiner to again ensure that the driver is going to be able to operate the vehicle safely. Specific requirements for commercial drivers is that the vision is at least 20-40 or better in each eye, and the field of vision is at least 70 degrees in each eyes. And they're able to recognize the yellow, green, amber colors you can imagine for traffic lights. It's very important. And they can also perceive a forced whisper at five feet or an average hearing loss in the better ears, no greater than 40 decibels at the 500, 1,000, and 2,000 hertz. And again, they can wear their hearing aid for this test. There are also hypertension guidelines that are standardized. So the guidance is typically printed on the exam form. So I provided a sample of the guidance is also changed for hypertension. So you can take a look at the chart. But essentially, if you have stage 1 hypertension, you can get up to a one-year certification. If you're normal, you can get the full two years as long as the rest of the physical exam and lab work is normal. Stage 1 hypertension, one year maximum. Stage 2 hypertension, typically you get a three-month certification. And stage 3 hypertension is usually disqualifying. Some disqualifying conditions to be aware of is a current seizure disorder. There is a seizure exemption available if you can provide documentation that the seizure disorder is very well controlled and you're on the appropriate medications. Also, severe vision impairment. By this, I'm mainly talking about monocular vision. But there are vision waivers or exemptions that are available. But you do have to still be able to pass the basic vision requirements that I had mentioned before, 20-40 vision with both eyes, and then also the 70-degree and be able to discern the three different colors. Current insulin-dependent diabetes. This is something that was actually changed in 2018. So prior to that, this was a disqualifying condition. But now there is exemptions available if you can, again, provide documentation that the diabetes is very stable despite the use of insulin. Current drug use or abuse. Marijuana is disqualifying. Methadone is disqualifying. Marinol is not disqualifying. And then Meniere's disease, because it can cause vertigo, it's oftentimes very unpredictable when the onset occurs. So this is a disqualifying condition. And a person is qualified to drive if they do not use controlled substances, Schedule 1s, an amphetamine, narcotic, or any other habit-forming drug. There's an exception if they have a prescription from a licensed medical provider who is familiar with the driver's medical history and assigned duties and has advised the driver that prescribed substances or drugs will not adversely affect the ability to drive safely or operate the motor vehicle. This is kind of iffy, and I think it is dependent on the medical examiner to also determine if they feel comfortable with the abilities of the driver. Now, again, the main question you're asking yourself as a DOT-certified medical examiner is, can this driver perform the essential job functions safely? If there are accommodations that are needed, that's fine, but is it really realistic? And what are the risks of the underlying diagnosis or therapy, and are they going to affect the safe operation of the vehicle? So, this is a question on the FMCSA FAQs for medical marijuana. Can a driver be qualified if they're prescribed medical marijuana? And the answer is no. Drivers taking medical marijuana cannot be certified even if they reside in a state where medical marijuana is legal. So, limited certifications and SPEs. We talked a little bit about the limited certifications when I talked about the blood pressure criteria. So, drivers who do not qualify for a two-year certification may be given a limited-time certification by the examiner, and blood pressure, again, is a specific cause for those such certifications. You can also do a skills performance evaluation, and the time that I think about when this is most applicable is for an applicant that has a limb impairment. And so, the medical certificate must be accompanied by the SPE documentation of what the driver is capable of doing, and what the application capable of doing, if they need any proper accommodations, but then the driver does have to carry the SPE as well as the medical certification. So, let's switch gears a little bit and do a practice question. Alcohol and drugs are associated with A, increased work-related injuries, B, impaired job performance, C, increased medical costs, D, decreased performance on specific tasks, or E, all of the above. And the answer here is E, all of the above. So, let's look at some data from the National Institute on Drug Abuse. Surprisingly, nearly 75% of all adult illicit drug users are employed. So, these are people that may have the consequences that we mentioned before at the workplace. When compared with non-substance abusers, substance abusers' employees are likely to change jobs frequently, be late or absent from work, be less productive employees, be involved with workplace accidents, and or file a workers' compensation claim. Now, let's talk a little bit about alcoholism. And the effects depend really on the study that you're looking at, but more than 50% of traffic fatalities, murders, rapes, suicides are related to alcohol use. And 3 to 13% of people are heavy drinkers, which is five or more drinks on five or more occasions in the past 30 days. We do see there's more predominance in males than females. There is an increased risk of alcoholism among certain professions, including movers, transport workers, bartenders, waiters, and longshoremen. And about 6% of workers overall in the U.S. workforce are considered heavy drinkers. There are a few different questionnaires that can be used to assess for alcoholism. The one that I think is the most popular is the cage questionnaire, in which you ask about cutting down if the employee or the patient has tried to cut down in the past, if people around them have annoyed them or criticized them about the drinking, if they've ever felt bad or guilty about the drinking, or if you've ever had to have a drink first thing in the morning or as an eye opener. So, if you have two out of four that are positive, that does indicate a significant risk of alcohol dependence. And there are other questionnaires, as I mentioned, that you can use the audit questionnaire or the masked questionnaire as well. Now, here in the U.S., fentanyl has become a very common drug of abuse. And according to NIDA data, if you look at the years 2018 to 2021, you can take a look and see the number of pills containing fentanyl that were seized by law enforcement during those years has increased significantly from 290,000 in 2018 to over 9 million in 2021. It's a synthetic opioid. It's about 50 times more potent than morphine. The overdose deaths in the U.S. during the months of December 2019 to 2020 exceeded 100,000, and that was the first time in history that we've had that happen. The preceding 12 months prior to December 2019 had a death rate of 91,000. So, as you can kind of tell by the data, the number of deaths is slowly increasing year over year. It does seem to affect minority communities at a very alarming rate, and non-Hispanic Blacks are the ones that have the highest death rates. It's also important to understand the symptoms of fentanyl. If you look at the NIDA website, many of the drugs that were laced with fentanyl, the users of that drug or medication didn't know that their pill was actually laced with fentanyl. So, if you suspect it as a provider, it's important to know because you can potentially give them naloxone and get medical support for them quickly. So, the patient may appear unresponsive. They may have irregular breathing. They may appear gray or blue or have a pale color. So, very important to understand the symptoms so that you can hopefully get the medical treatment right away. Another very common drug of abuse is marijuana. It's actually the most common positive workplace drug screen. I think that continues to be the case year after year. THC is the active ingredient, and the symptoms are typically apathy, impaired judgment, and decreased problem-solving skills. It can lead to lung injury, including bronchitis, and usually when smoked, the effects take effect within a few minutes. Other drugs of abuse are cocaine that can come from the cocoa leaf. When it's freebase, it's in its pure alkaloid form, and it can be smoked. When it's crystalline salt, it's insufflated, and this can cause increased heart rate, blood pressure. It can cause a myocardial infarction, seizures, or CVA. Next is amphetamines. They typically have a longer half-life than cocaine and can cause psychosis and motor agitation. And then you have methamphetamines, which causes decreased memory and psychomotor dysfunctions and can also lead to this out-of- control psychosis. Next, we have the opiates and opioids, and their medical use may cause dependence. They're seen as depressants that cause mental and psychomotor slowing. The opiates are the natural occurring narcotics, such as heroin, morphine, and codeine. Many of the opioids are the synthetic agents, so here's where you have the oxycodone, hydrocodone, and hydromorphone. In these patients, you may see needle tracks, meiosis, constipation, weight loss, and infectious complications. You can also have the sedative hypnotics, such as the barbiturates, benzodiazepines, and for these medication classes, the half-lives vary. So let's test out our knowledge of the practice question. Which type of workplace drug testing yields the highest rate of positive tests? Is it post-offer pre-employment, return to work, reasonable suspicion, or random testing? And the answer here is C, reasonable suspicion. So these are the people that are coming in to get tested because a supervisor or a co-worker has seen some apparent behavior and so refers them, and so these are usually the highest rate of positivity amongst employees. Now we're going to talk about a medical review officer and a little bit about what their requirements and responsibilities are. So current requirements are the completion of a training course, as well as a certification exam, and then also continuing education and re-examination to maintain your certification as an MRO. The DOT has a set requirement and a set percentage of workers in each agency that undergo random urine drug testing and breath alcohol testing on an annual basis. The rates are set annually based on experience data, and so the testing rates differ by agency. So in 2015, the FMCSA rate for CDL drivers for drug testing was 50%. The DOT requires that a five-panel test be given to each potential driver. The five panels include opiates, cocaine, PCP, THC, and amphetamines. You can also request an expanded seven-panel if needed, but the requirements for five-panel. So what types of workplace drug testing programs are there? Typically, there's post-offer or pre-employment testing, and these are aimed at identifying new hires and or applicants who use drugs. Remember that current drug users are not qualified under the ADA as a disability, except for alcoholics. And then random drug testing is also for deterrence. The percentage of employees and frequency of selection per government regulations or employer policy. If the test is positive, then it prompts a substance abuse professional referral and follow-up program, typically. And these follow-up programs can last for some time. Some healthcare systems have follow-up programs that last for years, up to five years for healthcare providers. There's also reasonable suspicion for cause testing. Again, these are the employees that might be referred because they saw some abhorrent behavior was observed by a coworker or supervisor. And so this is the most common positive test. There's also post-accident testing. The DOT specifies the timeliness of testing for this is 32 hours. And there's also individual deterrence testing programs, also known as follow-up testing programs. So this includes an SAP substance abuse professional initial and follow-up evaluation and includes treatment as indicated by the SAP. There's a return to work period, as well as 12 to 20 months of follow-up testing as per SAP recommendations. There's also some non-regulated testing. This is just for the sake of thoroughness that I'm including this in here. There are employer-based drug testing programs that are not required by law to be in place, but some employers do want to have testing programs in place. There's expanded panel tests that are available. I think I'd mentioned those before. And then there's split and non-split specimens that are also available per the MRO's evaluation of the initial specimen. And then there's alternate specimen media that can also be used, such as hair, oral fluid or saliva, and then sweat and blood. The MRO has a very strict process that must be followed in order to ensure validity of the testing procedures. So one is the chain of custody paperwork that the MRO must review to ensure that the specimen has only been in the proper hands and has been handled appropriately. The MRO is also responsible for contacting the donor, confirming their identification, performing an interview to determine if there's a legitimate medical explanation for a lab result that seems abnormal. The MRO will also verify any prescriptions and or medical documentation. So if there are prescription medications that can help explain why a drug test might have come back positive, the MRO will ask for the proper medical documentation to verify that they are in fact on that prescription. And the MRO can also write a safety letter if indicated to the employer to let them know that there is a cause for concern and so the employer is aware that the person shouldn't necessarily go back to work right away. The MRO will also determine the status of invalid dilute substituted specimens and cancel or determine them as refusal to test if indicated. They will educate the donor regarding split specimen request process for DOT. For example, this happens if the drug test comes back positive and the employee thinks that there was some break in the chain of custody and so the MRO can offer a split specimen exam at the employee's cost to verify the results of the initial drug test. And then the MRO is responsible for reporting the results to the designated employer representative or the DER. And this is typically the only person in the company that the MRO will communicate the results to and the DER will then take it up to the right, the appropriate parties within the company. So now what is shy bladder? This is a phenomenon that's tested quite frequently. So shy bladder occurs when you're unable to provide 45 mils of urine in one void. During the time period where you're asked to give a specimen, you are provided up to three hours to provide the specimen of 45 mils of urine. You're also provided 40 ounces of fluid and you can discontinue collection at three hours and report it as shy bladder. Now the DOT does require medical evaluation to determine if there's a medical reason for the inability to provide a specimen. If there's no legitimate explanation for why you're not able to produce a specimen, then that's considered a refusal to test by the MRO. So now let's test out our knowledge of the practice question. Which of the following is not an acceptable explanation for a trucker not being able to provide an adequate urine specimen during the shy bladder evaluation? A, new onset anxiety, B, oligarch renal failure, C, outflow obstruction, or D, urinary tract infection. Well, B, C, and D are medical reasons of why someone may not be able to provide a specimen. So the answer here is A. Now let's talk a little bit about the DOT and alcohol use. Performance of safety-sensitive function is prohibited per DOT if the alcohol concentration is 0.02 or greater, if the driver is actively using alcohol, or within four hours after the use of alcohol. For flight clues, it's a little bit different. It's actually eight hours. And what are the employer actions that must be taken per DOT if a specimen comes back verified as positive, adulterated, or substituted? Well, number one, they have immediate removal from any safety-sensitive position. Some employers may also have stand-down waivers from DOT, and that permits them to remove the employee from their position prior to the full MRO review. And then the next step is a referral to a substance abuse professional. Let's test our knowledge with another practice question. An MRO can determine that a test reported by a lab as positive for cocaine is negative if the donor, A, alleges passive inhalation, B, uses a lidocaine patch for back pain, C, drank Inca tea, or D, had cocaine use with a recent ENT procedure. So the only legitimate medical explanation would be D, and the driver would be required to provide some documentation of the procedure and that the cocaine was actually used during the recent ENT procedure for it to be considered negative. So let's talk a little bit about employee assistance programs. They were begun in the 1940s and really influenced by the models of Alcoholic Anonymous. They evaluate and refer for treatment, and they really help organizations resolve productivity issues. They also provide training for employees and offer short-term counseling. Some employers may have a set of three sessions that are covered by the employer, or five sessions that are covered by the employer if they're referred to EAP. And they help to identify employees with personal problems, such as drug, alcohol, relationship problems, family, or any kind of psychological issues. And then they make their appropriate referrals to psychiatry if they think medication intervention may also help. And workplace homicide is, unfortunately, homicide is actually the second-leading cause of occupational death after MVAs. Eighty-five percent of them are related to some type of robbery, and cab drivers have among the highest rates of workplace homicide. Retail sales also have very high numbers. And worker-on-worker violence is only seven percent of homicides. It's usually employee and customer-type interactions that result in homicide. Now, there are multiple risk factors that have been identified for workplace violence. One is when you have contact with the public. Secondly, if you've had any exchange of money that's occurring during the transaction. Three is if you have delivery of passengers' goods or services. Fourth, if you're working with unstable or volatile persons. I know in the hospital, oftentimes, our highest rates of workplace violence occur in the psychiatric units and in the emergency departments. Again, very volatile kind of situations. Working alone or in small numbers, working late at night or during early morning hours, and working in high-crime areas. And occupations with high risk of violence are retail trades and service industries. Healthcare workers, unfortunately, also have had a very high rate of workplace violence, and it seems to be increasing. And occupations with high rates of homicide include taxi cabs, drivers and chauffeurs, law enforcement officers, hotel clerks, gas station workers, security guards, store owners and managers, and then bartenders. We are at the end of our lecture, so I want to thank you for your time.

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