Hi, good afternoon. Thanks for joining us here at the 145 special. It's always a tough time right after lunch, so we'll try to keep you guys energized here. My name's Brett Perkison. I'm on faculty at the University of Texas School of Public Health. I've done a number of different research programs with heat stress. I've also been in the corporate environment where I've implemented heat stress programs in the past. So, glad to be here to chat with you today, and I'll let Dr. McCarthy introduce herself. Hello. Hello, everyone. My name is Rhonda McCarthy. I am a national medical director at Concentra for their medical surveillance services. I live in Waco, Texas, central Texas, so I've been an occupational medicine consultant and a medical director for several employers in the central Texas area. So my obvious interest in heat stress and heat stress medical surveillance programs. Thank you. So I have no conflict of interest, and as mentioned, Dr. McCarthy works for Concentra, and they do some work regarding heat stress evaluations. So what we're going to do today really is relate a lot to our experiences with heat stress surveillance programs, specifically Dr. McCarthy's specific heat stress surveillance program that worked very well with a local municipality in Houston, or in the Texas area. But before we do that, we're going to kind of take a large high altitude level on the issues associated with heat stress and industry, and how your industry or organization can benefit from a heat stress program. Then we're going to go into some detail on the design of a heat stress surveillance program, and then finally we're going to break that down into the different components of heat stress program. So why do we need to learn about heat stress? I think that's a pretty rhetorical question at this point. Yesterday, we attended Dr. Levy's excellent program on new heat stress surveillance design systems. Dr. Patz last night referred to heat stress, but the baseline is that ambient temperatures are increasing in Houston, that's very relevant to us, and that heat exposure is increasingly mentioned as a health hazard that all of us in occupational medicine need to be aware of. There are also a number of different OSHA regulations that are in place and being put forth in place, and so we're going to touch on that. And finally, this is part of one of the ACOM recent guidelines on heat stress that are outlined, of which we were both co-authors on that paper. So increasing ambient temperature. So I won't stay on this, Dr. Patz did a nice job, but the 10 warmest years in 143 years of records have been since 2010. They're increasing in not only intensity, the heat index is going up with that, and so areas that were formerly not, weren't too concerned about heat now should be concerned about it, and areas down in the Gulf Coast, those are prolonged areas. And so having these programs in place should be very much part of anything that we need to look forward to in the foreseeable future. So specific heat hazards related to health hazards. So we all sort of learn these kind of standard gradations of heat stress going from heat rash to becoming symptomatic in syncope and cramps to heat exhaustion and stroke. And obviously our goal is to always prevent that, to try to catch heat stress early on. One of the issues that we wrestle with when we're trying to analyze results of heat stress is how do you capture that? I feel like heat stress is one of those areas that is often missed in claims data. It's often a diagnosis of symptoms. And so being aware of that possibility, we increasingly need to be aware of other issues, like if you see traumatic injuries or skin burns can often be associated with heat stress. Obviously dehydrations or symptoms of dizziness. Also associated chronic illness can make people more vulnerable to the effects of heat stress. But in addition to that, also many of you are aware of renal pathology associated with heat stress, particularly right now in Central America among sugar cane workers have been a high degree of association with renal failure. It's not just heat. There's a lot of other factors that are being studied, such as pesticide use or sort of how workers work. But some of these cases are also being shown in North America. But it's something that we in occupational medicine need to be aware of is that there's this entity where you're having renal failure that's associated with heat stress in younger workers. Particularly rhabdomyolysis, that is something that is heat stress that it shows in the young and the old are traditionally susceptible effects of heat stress in workers that are exerting themselves. Increasing rhabdomyolysis is a factor in heat stress that can, again, when you're looking at claims data and you're trying to monitor what is the impact in my business organization to look at these claims data, there's something other than just heat stress. So we mentioned the federal kind of regulatory milieu here regarding heat stress. So we still have our General Duty Clause, which is a safe environment and that provides justification for OSHA to come in and look, usually in the case of fatalities, and that's in place. But in addition, which began in April 2022, is something called the National Emphasis for Program for both Outdoor and Indoor Heat-Related Hazards. What that is, it's not a new regulation, per se, with OSHA, but it's more states in regulations. It gives that General Duty Clause a little more emphasis to go in and monitor worksites specifically regarding heat stress. This regulation was passed in April 2022 and will be good for three years till April 2025. But it's something to acquaint yourself with that sort of further outlines. Additionally, there are other issues of advanced proposed rulemaking. There is a federal heat stress standard that's been in both U.S. Congress and the U.S. Senate for several years now that provide more stringent guidelines. They haven't gone anywhere yet. They haven't moved out from their committee. But that's something that the rules have been in place for that, and they're ready to go. And how does that affect you while you're waiting? Well, you can utilize some of these factors that are being implemented in these proposed rules for your own program. And that's exactly what Dr. McCarthy did for her municipality program, and we're going to see some examples of how she put that in place. So, and I also mentioned the ACOM guidelines. And so, in ACOM there, if you look in JOEM, as outlined in the paper, there are some specific guidelines that you can have if you're trying to update your own heat stress program. And that talks about how do you measure heat stress, what are the processes in place in order to best measure that, how do you create an employer prevention plan, physiological monitoring, there are a lot of different ways that you can monitor for heat stress. How do you have the unacclimatized worker reintroduced into the work site? And there provide some guidelines on that. Even a worker that has been out of a hot environment for as short a time as two weeks, when they go back into that hot environment, there should be a re-acclimatization process. It does not take long for any of us to lose that tolerance to heat. And finally, what we're going to focus on mostly today is medical surveillance programs. How does a medical surveillance that directly involves our departments come into place for anticipating those people most susceptible to heat stress? And finally, return to work is also outlined in the paper about when somebody has had a heat stress injury or one of those other chronic illnesses that I mentioned, when should they be ready to return to work? So I would refer you to those guidelines. So heat stress medical surveillance is what we're going to focus on a little bit today. And if we go into detail, we're going to talk about the analysis of health information. We're going to talk about when you see abnormal trends, about when you should get more aggressive with your heat stress program. Where are the issues? How do you break it down as to where your heat stress prevention program is having some problems? And how can you provide constructive feedback to the employer to improve their program? This comes from NIOSH about the components of a medical surveillance program components. Those of you that have been in the field, this is kind of your bread and butter for medical surveillance. But for the newer members to our field in the audience, we've sort of outlined a few different, if we break down what is a medical surveillance program that we're going to talk about into these six different components. So a goal is to preserve worker health, obviously should be the underlying issue. And to determine and anticipate when this person is really fit to work in a hot, hazardous environment, to do early screening and detection for health effects of that hazard, which is something why Dr. Levy's physiological measuring of sweat and perspiration is really intriguing and it really gives us a lot more tools to do that. And then identifying problems in worksite prevention, where there are problems in the worksite area and some strategies to improve that. We've talked about what is a hazard for heat stress, environmental heat. But not only is it the ambient heat, but it's also what is the heat, individual heat of the person. And that's where personal monitoring, both for that microenvironment where the person's working but also underneath their equipment, underneath their FRCs, that person may indeed be a lot more under more heat stress and duress than what the ambient temperature is showing. And then also what is the work, physically demanding work that puts them at risk for heat stress. These are some of the main areas. Many of you may work in these industries, but these are some of the main problem areas, if you will, where we often see that. You can see in agricultural, it was one of the driving forces behind the establishment of the Cal-OSHA heat stress standards because of the vulnerabilities of agricultural workers. Houston, in oil and gas, where I work, there are a lot of issues out there both on offshore oil rigs and working in construction. Landscaping is one of those areas that sort of fall under our radar screen because there's a lot of small organizations in that. But you can also see iron and steel mills and indoor heat stress is also an issue when you have the ambient heat plus the indoor heat that's from a manufacturing process. Those workers are at risk, too. And finally, stakeholders, again, I think all of us that have been in the field for a while know that it's not just focusing just on the workers, but it's also in order to have a successful heat stress program, you've got to involve health and safety. You've got to involve human resources and the clinician as well as the workers. Workers at risk, we've talked a little bit about some of those individuals that are at risk. Those that wear protective clothing where they can't release a lot of heat for physically demanding work. We talked about unacclimatized folks and then individual risk factors. And individual risk factors, there are really quite a lot of those. Our workforce population is aging, so age over 60, you don't deal with heat stress as well. The prescribatory system is not working as well. Obesity, again, a trend in the American workforce population we have to be aware of. If you've had a prior heat risk illness, that is a risk factor and so that's where your medical surveillance program comes in. Women in the workforce, pregnant women are more at risk. All those chronic diseases, which is a shout out to Total Worker Health where we're looking at chronic diseases in addition to workforce risk. That's where really a kind of a holistic approach to your heat stress program should come into place. In addition, sedentary workers that aren't used to the physical fitness. If there's illicit drug use, medications, one of the classic ones is the high number of people on anti-hypertensives and diuretics put one at risk for heat stress, so being aware of that, developing trust with your workers so that they can tell you about some of these medications. If you've had an acute illness, if you've had a viral illness, or if you've had skin conditions where your prescribatory system is not able to work as well. So the medical evaluation, I'm going to turn it over to Dr. McCarthy. Thank you. Thank you, Brett. So Dr. Perkinson has reviewed the initial stages of creating a medical surveillance program. He's gone over addressing the goals that you want to be in agreement with your employer and both be on the same page for those goals. And then also identifying what the actual hazard is and the health effects and then looking at who the stakeholders are. So now we go on to the medical evaluation. Ideally you want to have a program oversight by an experienced clinician. Occupational environmental medicine clinicians are a perfect clinician to provide that oversight. Worker participation, we touched on worker participation, but it should be those workers identified as being exposed to NIOSH's heat recommended exposure, sorry, recommended action level. So their RAIL. And that you can find in NIOSH's recommendation for a standard, which I will show later. The medical evaluation. Medical evaluations, it is recommended they be provided baseline as they are going into a hot environment or pre-placement, periodic, annually, and return to work. The written medical opinion. The written medical opinion should be provided to the employer and to the employee. Specifically to the employer, we don't provide any confidential information, but relay the work status. Are they fit to work in the heat exposed environment? Do they need any restrictions, temporary or permanent? I want to get this. Okay. So how do we perform that medical evaluation? For myself, I have, as I said, I work in central Texas, very hot, subtropical, humid environment. I've worked for an indoor and outdoor, that have employees that work indoor and outdoor exposed to heat. And if you have a small employee health department, sometimes you have a large number of employees and it has been my method to use a screening questionnaire to establish those risk factors with employees. And it also allows, it gives them just an introduction into what are those risk factors. Right now, while the participation is voluntary, it's just been a great way to introduce this to employees. So a screening questionnaire, the goal of it is to identify those risk factors that can put that employee at increased risk for heat related illness. Dr. Perkinson discussed those personal risk factors that were listed on the other slide. And what is the outcome? The outcome of the screening questionnaire, which should be provided confidentially and provided back to the supervising physician or the employee health clinic confidentially, is to be able to divide out those employees that have no, that report no increased risk factors and those employees that do report risk factors for a heat, that placement increased risk for heat related illness. And you want to have further evaluation with those employees that do have the, do report risk factors prior to their work, prior to their continuing work and prior to their work in a hot environment. So the medical evaluation, the in-person medical evaluation with exam and testing may be your medical surveillance program, or it may be what the further evaluation after initial screening questionnaire. Regardless, the medical and occupational history, the medical and occupational history should focus on those risk factors. We discussed the environmental risk factors, so every, the employees that you see can come from different environments. So some of us work in occupational health clinics that may see employees from different environments and some of us work with one employer and we know what that environment is and the specific job descriptions. But for that employee, they may work first shift, second shift, third shift. Second shift is notoriously the hottest work shift. And you need to know specifically what PPE they're wearing, what clothing they're wearing. Are they wearing a respirator that can add to their heat stress or their heat load? And then also the medical history that identifies their own personal risk factors. And also as far as their shift too, are they working overtime? Are they working another job that where they have heat exposure? And what's the duration? Some individuals work eight hours, some 12 hours. The testing, I have not personally performed testing. It is recommended by the ACOM guidance. And now as we're learning more about the, how the kidney plays a role and we're learning more with the, like the sugar cane workers in Central America having the acute kidney injury that repetitive work and heat with increased physical demands and dehydration has led to acute, more cases of acute kidney injury and then that move on to chronic renal disease. So getting baseline serum creatinine and glomerular filtration rate and checking that periodically may be a good way to help look at early health effects. Also creatinine kinase can be evaluated with acute disease. And again, the written medical opinion should be provided to the employer and discussed with the employee. This is a good time to discuss with that employee what their personal risk factors are, what they should look for, should they develop signs of heat stress and when they should report to the employee health clinic or the A health clinic and to their supervisor to get them out of that hot environment. And this has been, there are many employees that have, that may need that empowerment to report those symptoms. And they may have ideas of, you know, going into a cold environment may make them more at risk for developing a heat illness or drinking cold water may have them have adverse conditions and make it worse for them with heat stress. So you can help alleviate some of these ideas or help educate them on some of these ideas that employees may misunderstand as far as prevention for heat illness. The return to work evaluation is a very important component for any medical surveillance program and just for occupational medicine physicians in general. If you have an employer that you feel is at risk, you know that they're in construction in a state that is typically has hot and, you know, with climate change, the states that are experiencing hotter summers are extending, but return-to-work evaluations for heat-related illness or extended absence, it's important for the evaluator to ensure that the worker, prior to returning into that hot environment, is asymptomatic, especially for heat-related illness or the illness that they were out for, if it was an illness, and that their abnormal biomarker, should they have had a severe heat exhaustion or heat stroke, have returned to normal. Even those with acute kidney injury tend to have the serum creatinine as an abnormal biomarker. So for heat stroke, you want to ensure that the BUN, the creatinine kinase, the aspartate aminotransferase, and the alanine aminotransferase, and the lactate dehydrogenase have returned to baseline. If they haven't, it may warrant a referral back to the specialist. Also prior to return to work, especially for heat-related illness, you want to contact that employer and make sure that they have an employer action plan in place to prevent reoccurrence. We don't want this happening again. So one of the risk factors for heat-related illness, as you may all know, is a prior heat-related illness. They may be less tolerant in the heat. And then back to this re-acclimatization. With the baseline and even the baseline exam for pre-placement and a baseline for a medical surveillance exam, this is an opportunity to also, if an employer does not have a heat illness prevention program that includes an acclimatization plan, you can provide that acclimatization schedule with your work status report. So say the employee has no risk factors, is able to work in the heat environment, and they don't have any increased risk factors, if that employer does not have an acclimatization schedule and they're coming in, say, in July for a construction job, I would go ahead and write for the NIOSH's acclimatization schedule. So here, we'll just look at that a little bit further here. So here's just a sample of a, you can get this on OSHA, and this can be placed at the work site or in an office, but it's to show, you know, that the acclimatization, basically, that is recommended by NIOSH. So acclimatization is critical in preventing heat illness and heat fatalities. I know most of us know this, but we can't, I can't emphasize enough that 50 to 70 percent of outdoor fatalities occurred in the first one or two days of work. And these are young people, young healthy people that die on the first one or two days of their job. So that is significant. And we, as occupational medicine physicians, we should be familiar with their, with, generally with their employment, what their physical demands are, if they're going into a hot environment, and we can recommend that on their work status. So I believe that the OEM clinician has an important role, regardless of this, if they're participating in a medical surveillance program or not. So it's usually well-tolerated by employers because you start at 20 percent the first day and you add 20 percent each additional day. So by day five, they're working at 100 percent. If you have somebody, and that's for healthy people, if you have someone that has illness or significant risk factors, you may want to extend that to seven to 14 days, as you deem appropriate. So now we're back on results, so we're two results. So we discussed that the results, medical surveillance provides a feedback mechanism to the employer. So these results are important. So what results are you looking for from a heat stress medical surveillance program? And what are the results that the employer is interested in? So if you want to sit down with the health and safety manager at least once a year. For myself, I often worked with them quarterly or more than quarterly. Basically we sat down and talked any time there was a heat-related illness. So you may be doing it more frequently, but at least once a year, and talk about the first days. There's a lot of heat-related illness first days. So there's, because the treatment for heat exhaustion often is just rest and fluids and some time away, and then they can go back into the hot environment. So those are often the day of injury and then not yet recorded as a heat injury. So how many first days were associated with the heat? How many heat-related illnesses were associated with the heat? And then how many absences, what number of absences that could pertain to the heat? And then also looking at any job clusters that are heat-related, so that they can focus on that specific job. And the safety manager can use, or other management can use this information to develop worksite interventions. So the action plan. We all recognize this, the NIOSH's hierarchy of controls. And so if the numbers went up as far as heat illness or first days, or you have a job-specific clustering, you want to focus on where that is occurring and what can you do about it. And this may be something that you can interact with the manager as well. Well, the first obvious one, the best, is eliminating the hazard. Often that can't be done, and as we discussed, the climate is changing, it's getting hotter. And next would be substituting. If an employer had a machine that was creating a significant amount of heat in the indoor environment, then they could replace it with a more efficient machine that wasn't, or they could guard it with a more efficient machine that wasn't producing any heat. That may be considered maybe a substitution. That's pretty expensive for an employer. That doesn't often happen. So we usually are looking at engineering controls, administrative controls, and PPE. So we look to cool the environment. So on cooling the environment, the most often used, if applicable, is air conditioning. Outdoors, we have to use cover, we have to use shade, and fans, if available. And also indoor, we can use fans as well. Administrative controls are the acclimatization program, as we discussed. That's an essential administrative control. Also, altering the work schedule. If you can have the employees work at an earlier time, increase the employees during the hotter part of the season. Even for indoor workers, if they don't have ventilation or they're not keeping the environment cool, those indoor work environments are often significantly hot during the summer months. So adding extra employees or limiting overtime hours. Also, yes, scheduling the cooler hours. I know that in Arizona, sometimes they limit their work just to the nighttime hours to be able to do the physically demanding outdoor work that they need to do. And PPE, which is the least effective, but a very important consideration. If they have to wear Tyvek suits due to other chemical hazards, you need to limit that time in the Tyvek suit to even shorter periods. You want to think of clothes that breathe, so that's an important factor to consider. There's also, as Brett said, there's monitors that you can use to sense sweating that may be utilized with these PPE. And there's a vest, a cooling vest and other items that are being developed that can help with the cooling. Whoops. So these are the resources that I use and I recommend that you use just for creating a medical surveillance program. Especially if OSHA is, over time here, develops a heat standard, what OSHA is recommending and they refer to NIOSH's criteria for a standard throughout their technical manual, section three, chapter four on heat stress, then you're already in line with possibly what will come out as a standard. Looking forward to that. So these are great references. And then I want to move on to the impact of a heat-related illness prevention program that includes medical surveillance, and then the program, the effects without medical surveillance. So we just have a unique situation here where we can look at the impact of a program in a cohort of outdoor municipal workers who are exposed to a subtropical, humid climate and their job description states that they're exposed to extreme temperatures, so cold or the heat, and they have physical demands of medium, heavy, and very heavy as defined by the Department of Labor. So this cohort, I noticed working with this municipality that I was seeing too many heat-related illnesses and then looked into it further, there was no heat illness prevention program, really no prevention factors in place for this municipality and these workers. So I went ahead and used OSHA, NIOSH's information, and extended over such a period of time, I went through two revisions of NIOSH's criteria for a standard. So I worked from 2000, I used data from 2008 to 2017. So this is over 2008 to 2017. Myself, Dr. Fran Schofer, and Dr. Judith McKenzie did a retrospective analysis of the information that I gathered working with these individuals. So the heat illness prevention, and I'm just giving a high level, the heat illness prevention program included supervisor and employee training on heat stress, heat-related illness, and prevention measures, first aid and emergency response procedures, recommendations for water rest shade, a climatization program, and medical surveillance. And so I'm going to talk a little bit more about the medical surveillance. Because there was myself and two nurses, and there was hundreds of workers, I, thinking of a way to screen the population because I could not see them all, we went ahead and developed a heat stress questionnaire that could be confidentially administered to the departments that were at risk. This questionnaire was basically, took the information out of NIOSH and other information of the risk factors, so chronic conditions, certain medications, BMI, you know, other environmental factors, and physical fitness, et cetera. And we dispensed those, you can use this, so then we returned these questionnaires and reviewed them, and like I said before, separated them into workers that reported no increased risk, and then workers that had one factor or more, one factor, and then workers that reported two or more factors. The workers that stated that they didn't have any increased risk factors, and this is self-reported, and their BMI was under 30, and this is self-reported, we went ahead and cleared for, to continue work without restriction. So they were cleared, we did provide them a letter, letting them know that they were at no increased risk, and gave them additional information, they all had training, they all had the common training on heat stress intervention. Workers with one risk factor or more, they were brought, they were invited to come into the employee health clinic, where we confirmed their information that they reported on their chart, confirmed their BMI, and then also did, they usually saw the RNs, and their vitals were taken, checked their blood pressure, if they reported diabetes, checked their blood sugar, make sure their conditions were stable, and then did some training that focused on their individual risk factors and what they should look for, specific for their personal risk factors. Workers with two or more risk factors were scheduled an appointment, and just like the exam that we discussed, went ahead and focused on their risk factors, any abnormalities that they may have, and looked for, just basically to ensure that their conditions were under control. Those who had conditions that were not under control, and we did this, and for this cohort, since they were primarily just exposed in the summer, I looked at them in the spring, so if they did have to be on restrictions, they were not removed from their job, they could go ahead and correct any uncontrolled hypertension, or uncontrolled diabetes, or so forth, with their primary care doctor before the hot season began. So I restricted them from work in the hot environment, but that encouraged them to come back before the hot season to go ahead and get that condition corrected. But that puts themselves at risk for a significant injury, illness or injury, and others. So what did we find? With the retrospective analysis, we found three main findings, three salient findings. Workers with two or more risk factors for heat-related illness were more likely to develop a heat-related illness. The median cost, workers' compensation cost, went down by 50% per HRI, per heat-related illness, and the total number of heat-related cases decreased after implementation of the heat stress, the heat stress prevention program. So here on this slide, you can see that we have the individual risk factors, none, one or two, those without, those in the program without a HRI, and these with heat-related illness. And this shows the information, and with the analysis, it was statistically significant that workers with two or more risk factors. So some of these workers may have not voluntarily participated in the program, and then we did have heat illnesses, and those with two or more risk factors were more likely to have a heat illness. And this, what this tells me is that it is important to identify those risk factors, and this is where the occupational medicine physician can come in and help with that counseling. So the median cost per injury, we have on this left side here, before the program and then after the program. So the median cost incurred decreased by 50% per injury, so the median cost per injury. And what this told us is that the heat-related illnesses were, employees were reporting their symptoms earlier, so they weren't as significant. So they came in earlier, as we instructed them to, when they had signs and symptoms of heat stress, and so we were treating less severe symptoms. And then the heat-related illness frequency went down over time. So this is before the program, and then this is the year we started the program, which I expected the illnesses to go higher, because everybody was told when to report their symptoms, but actually 2011 for Texas was a very hot year, is one of the hottest years reported in Texas for a good period of time. And then after that, with the program, it went down, it gradually down, until the last two years of this, what we analyzed, we had no reported illnesses. So this was just tremendous. If you, at the time that I've discussed this, in the past, in 2019, that, you know, at that time, that was the hottest decade on record. So there was no temperature difference, it wasn't that 2016 and 2017 were cooler, they were still, we were still at 90 degrees or above through the summer months. But then, this is where Dr. Perkinson and myself come in, we decided we wanted to go back and look, so what's happening after 2017? In 2018, so what's happening after 2017? So we know that with the program, with training, acclimatization, and medical surveillance, we had decreased heat-related illnesses, decreased cost per illness, and two or more risk factors were associated with the heat illness. But in 2018, the heat stress medical surveillance program was discontinued at the employee health clinic. They wanted to focus on primary care, maybe we did too good of a job, and it's like, let's decrease some other issues. And so, they were still treating heat-related illnesses, but the medical, and they were still providing the supervisor and employee training prior to the hot season every year, and the supervisors were implementing the acclimatization program, 20, you know, 40, 60, 80, but it was not necessarily with a physician. What we found is looking at, so then we did a retrospective analysis looking at just the program years and after the program years. So this is with medical surveillance, and without, and then when the, after the program years. So again, you have these numbers where it's higher, and then it's going down, and decreasing to where you have no heat-related illnesses, and then it starts jumping back up. And for cost, the, what's very interesting is that the cost increased by, median cost for heat-related illness increased tenfold. So we have a violin plot here that this is during the program. So during the program, we had decreased cost per injury, but after the program, the numbers jumped up to where we have like in the 10,000s, so per injury. We don't have that much data. We don't have that many, so we don't have a big plot here, but the cost increased tenfold after. So in conclusion, a comprehensive heat illness prevention program that includes medical surveillance can decrease heat-related illnesses and associated workers' compensation costs. So most importantly, can protect your, protect heat-exposed workers. So the roadmap for medical surveillance program, for any medical surveillance program when you're looking at a hazard is to identify your goals and your hazards and what are the health effects. Look at, determine who are the people that should be involved in the program, what medical evaluation makes most sense to screen for the hazard and what are the results that you yourself are interested to look at early health effects that will help you identify early health effects and what is the employer interested in as far as aggregate data that can be a feedback to them to make an action on their engineering and administrative controls to preserve worker health and keep them safe in the work environment so key takeaways heat illnesses he related illnesses are preventable recognize those employers and workers who have risk factors regardless whether you're working with a medical surveillance program or not and but then work with at-risk employers to develop a comprehensive heat illness prevention program that includes medical surveillance using these recommendations from ACOM, NIOSH, and OSHA. Thank you. If you have questions feel free to come up and use the mic or we'll have a recording. We welcome your your input on your own experiences as well as questions for others. Always learning. Hey, good talk. Thank you. I'm David Cathcart. I'm a physician a medical director at BP. We've had a and we take care of a lot of our folks in South Texas where we had some petrochemicals plants very very hot they have to wear fire retardant clothing. I put together a surveillance program that I thought would be just beautiful it was just pretty much like you described had mandatory testing and then we were shut down before we actually got it off the ground by our legal folks because it was non-regulated testing. So can you speak to that at all about setting up a surveillance program that's not regulated and and enforcing employees through that a mandated program such that or just purely voluntary? So the programs so I definitely had to have employer buy-in and I did work with several it I was a broken record for many years and and some of the employers that were not interested were unionized facilities. I offered training just training alone I offered a self evaluation. I did different things because I ran into the same problem because it is not regulated by OSHA it's not mandated and and so but seeing these heat illnesses over and over again and and and how they affect affect the working population. So it needs buy-in from the employer it it can be voluntary if you provide the training if you're part of the training and the employees trust you as part of you know as their medical director and if they see you for other injuries and illness then it may be more accepted by the by the employee population. I was just gonna gonna add you know I think also that the scene is changing I think employee the University of Texas is as a group we're often approached by different companies there's a lot of strong desire from operations in different companies to do something about heat stress they're looking for answers and so I think the legal environment is is changing especially if you make it a voluntary program it's also something workers want they they they are wanting this from employers and it's becoming an advantage to implement a program like this if it's done in the right way rather than as a disadvantage. Right now I mean many years ago we rarely talked about the heat illness and the effects of heat illness and and you know we've considered the numbers low and not underreported so I think there's more acceptance and employees want that information and so it may have been just the timing of it so but I think that it's it's worth to continue to try to to see if you can implement that program. Thank you. Good afternoon I'm Melissa Broadman from Georgia thank you for the great talk. Any ideas about bringing people back to work after rhabdo like what should I think about monitoring I've been looking for like a standard and any thoughts about that after they clearly had rhabdo they were out for a few weeks few months coming back to work in the heat of the summer. Right so the so the return to work evaluation talked about biomarkers that you so you want to make sure that they're asymptomatic right that they're not having any symptoms of heat intolerance which they may if they're out of work they may be able to report to you that their exam is normal you may do other studies other than just the biomarkers but I'm just sure that they have a normal exam I guess they're being released by their treating specialist. Yes released by the nephrologist they've been cleared by their primary is there any should I bring them in once a month for C not a CPK but maybe creatinine or but their biomarkers are all normal at that point yes they come in with normal biomarkers right and then I would have an extended react acclimatization program and it may and especially after you know an incident like that you may just you know and see that employee back more frequently to see how they're tolerating it and if they start having symptoms and back it back it down you know so as long as they're they're they're tolerating it but you may even extend it out greater than two weeks you know three weeks four weeks for something that severe. And I think treating it as if it was a severe heat heat injury heat stroke you know with that kind of precautions that those guidelines would be applicable but it's a good question if that should be separated out you know in itself. Thank you. Hey good afternoon I'm Randy Conley with US Navy. We in the Navy and I think in the DOD in general really wrestling with the idea of medical surveillance programs in terms of enrollment because we already had a very young healthy population for the most part that a questionnaire perhaps would not necessarily screen through maybe anyone. I spent the last couple years on a carrier and you know we have young healthy population the question is you know with that population of what benefit is it to enroll them in a medical surveillance program where they they really don't have any of these conditions or comorbidities that would really screen through and I would certainly see heat illness on the ship. Right. Lots multiple times. Right. The kicker is that now with technology their spaces are nice and cool where they normally work however when you know if every sailor is a fireman and anytime we would have say any sort of general quarters drill where we would get into PPE and they would go into hotter environments that's when we would certainly see these particular events. So to acclimate to that was very challenging. So you know we have these sorts of challenges within the the DOD and the Navy specifically and you know how we enroll folks within a program that whether or not that's going to benefit them or not and how do we acclimate them to something that they don't necessarily see on it certainly on a daily basis. That's a that's a really that's a really good problem. I mean that's a really good interesting problem. So I'm assuming that the the ages that they will increase over time they're getting older and that if they have a heat illness anybody that's had a heat illness should be monitored should be part in part of a screening program. So once they've had a heat illness even if you have a smaller program they should they should be screened regularly and it may be that you're looking at some of those biomarkers following whether they have any developing any kidney disease that that is the recommendation by NIOSH. I think that where you're gonna have more power is your heat illness prevention program and then also just you know the hydration. I don't you know I don't know what your your I mean the military is I think it's done it really well as far as heat illness prevention but your prevention program in total having having the educate educating the the your the the officers on maintaining their hydration to avoid some of the heat illness and and the impact on their on their bodies. It it as as you know as I indicated I had quite a few that had no increased risk factors and so they were able to continue but you may have some that that may you may have someone that is becomes pregnant that they obviously need to to be talk about what to do at certain parts of their pregnancy and heat related activities. You may have somebody that has a skin issue and may have a congenital issue with with us and hydrosis so there may be other or metabolic so there may be other things that that might have been screened out regardless with the Navy but I'm just I agree that is a that is a problem to look at. I just had you know drugs alcohol sleep deprivation and obesity are also all factors that would be relevant to your population and possibly designing PT where they are keep they're not de-acclimatized you keep them out of the air conditioning and part of the PT to kind of keep them in certain shape. Right there are many young persons that I've said I saw that were because of their irregular hours they're drinking two three energy drinks a day and then and also and for the firefighters so I took care of the firefighters as well for firefighters they they were not part of my cohort because of their their their program their civil service and so with the training they they would often come in after they had a gastrointestinal and then have a heat illness after it because they didn't have that they didn't have that training to say I should report to my supervisor that I just spent two days vomiting and then they go out to on a drill and then have a heat illness or you know or I had heavy drinking the night before things that set them up for dehydration and then could lead to acute kidney injury thank you very much appreciate thank you hi good afternoon I'm Martha from Anglo American I wonder if you have any experience with wearables particularly in those employees with two or more risk factors I I personally do not because they were considered you know invasion of their their privacy I know Fred is working with yeah just in a pilot program we're actually doing this spring and if you if you heard the talk yesterday that was it was about a wearable you can get a transcript it was really interesting regarding perspiration and detecting when how much fluid is is being lost based on that it's in you know sort of the formative stages but I am working with a commercial product that looks at heart rate variability as a not not the heart rate but the variability in the heart rate as being an early indicator of heat stress before that happens it also looks at accelerometry and uses an algorithm to estimate core body temperature and it fits as a desk about this big right over over here on the left costal sternal angle and I right now I see that it accurately monitors you have to put it on kind of tight I can't see somebody wearing that all the time every time but I can see it as Sentinel cases where you have somebody out there where you're doing personal monitors as an indicator of heat stress for your for your population so there's a lot of a lot of interest in in products like this I think it's sort of early stages but that that product is Zephyr if you look that up is the name of the of the wearable monitor I was just thinking about like regular wearables Fitbit or just even a watch because you can have your own warning you know yeah that's what I that's what I recommend to the employees with their self monitoring I would explain the symptoms of heat stress they would have the information I often use the OSHA quick card that they could keep carry with them quickly I mean easily and and said they were having nausea headache you know dizziness and they're working in a hot environment or it's June July August in Texas then they need to sit down and rest they need to check their pulse and if it doesn't go down by you know a certain degree over over this 10 minutes and they're still sent or they're still symptomatic they need to come to report their their symptoms to their supervisor or come directly you know to employ health and so so that I said you know that they could use their own you know apps on their watches or their phone to check their pulse and so yeah I agree that they can do that self monitoring also for workers that work in a significant heat and there's an indoor we had a scale and have them weigh themselves before and after the work shift so they knew how much they had to hydrate before their next shift so in this self-monitoring and lastly I guess I just mentioned it's sort of a bread and butter of a heat stress prevention program is you have designated people health and safety or just a designated individuals to look out for others to make sure they're hydrating some of the early symptoms of heat stress there's confusion maybe mild nausea it's not very apparent so sometimes it's helpful to have somebody looking in on them as a second person observing for early signs of heat stress. And that's part of the counseling I did when I had people the individual counseling as I said you want to you want to to look out for others if somebody's not acting right they're confused you want to go ahead and notify your supervisor or 911 because this is a medical emergency and I've had them buy into it because you want them to be looking out for you and so that's a great point thank you Brett thank you Hi I'm John Vanderlinde from New Hampshire certainly not a climatologic hotspot but we do have hot periods of several days in a row followed by days of normal temperature which is cool for the rest of the country we do have heat injury people how do you suggest re-acclimatizing folks in in my kind of a climate where again it's hot for a few days not hot and then hot again and this is folks who wear multiple layers of protective clothing including Tyvek suits because of the difficulty and the time involved in doffing and donning the protective gear people tend not to drink much liquid because of the bathroom issue welcome your comments on this right right that is a that is a very good question so acclimatizing so they are they working in an indoor environment where it's hot or their heat is mainly generated from their personal protective equipment and their physical demands it's a little of both mostly indoors with poor ventilation and air conditioning I see well then I would I would just do it by time if they are especially if they're coming back after a heat illness you know regardless of the outdoor temperature if indoor they're having to wear this this PPE at specific physical demands and if they're doing it on a daily basis it's not emergency response as was discussed before then same thing 20% no more than 20% per day and that would be included the exposure and the physical demands okay and then you can vary it based on your clinical evaluation of that employee and their risk factors and what happened and you know and ensure that they're asymptomatic and if they're new to that environment you know the same same procedure thank you you know I just might add also that for those of you have national international responsibilities that preparing workers that aren't traditionally in cool areas to prepare for heat stress prevention programs that needs to be implemented you know classic examples what dr. Pat said last night in Washington DC where those individuals were experiencing hundred and ten degree temperatures when normally it was 70 degrees and they they had I think there was 800 deaths eight fatalities heat fatalities that but the programs need to be in place for that because physiologically people are the same they still need to go through this 20% ramp up and you need to have those processes in place now because increasingly areas across the country are going to be experiencing that this is going this is the new future for any of us in any latitude we are likely to experience a heat wave in any given year right maybe part of your emergency response plan you know so even if you're not experiencing or have it in place just have a part of your response plan of what to do should this occur I'd like to thank you both for an excellent presentation I love the slides are they available on the app they can be okay the the results the last part of the results is coming out we haven't published that yet but it will be coming out and then the early part of the data was published in 2020 it's in JOEM in the 2019 JOEM excellent thank you well one of my clients is a paper mill and paper mills are always hot and I just want to mention a case where we had an individual who was working on what seemed to us to be in ordinary day doing ordinary work of not particularly extreme physical demand develop muscle pain and weakness and fatigue and went to an urgent care and was diagnosed with heat stress or he actually even heat stroke which he did not have his labs revealed elevated CK's that were very significant but his creatinine was entirely normal and his medications included a statin which we had removed and I just wondered since statins are such common medications if that's something that you look at when you're doing post-offer and return-to-work evals oh well I would take take that as a factor when evaluating someone with acute acute injury as as as one of the reasons why their creatinine kinase could be elevated but their their elevations are our signet are fairly significant so you know and then you have you know the other clinical factors that would go along with the rhabdomyolysis or the heat stroke but yeah yeah you would take that in into consideration thank you thank you that's a great point thank you and before you all leave we appreciate your your attention and your questions one thing I wanted to emphasize at the end of this is this is really a tribute to dr. McCarthy she did this study really on her own not there was not any budgeted research time she she worked with affiliated academic institutions to do the analysis but any of you all have your own unique conditions in your workplace and it is possible for you to really contribute to this conversation implement your own medical surveillance programs you do not need to wait on this federal heat stress standard in order to activate this you know the time is is now and groups like the University of Texas School of Public Health we would be glad to partner with you are your your local institutions because you all have the employees and and we have the the academics to help kind of analyze the data so anyway thank you

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