11
Work Site Visits
VICTORDURAJ
Key words: modified duty, hazards, return to work, injury prevention
A better understanding of the health hazards of the workplace can be gained by work site visits. Physicians can use their observational skills to increase their understanding of work processes, hazardous exposures, potential adverse health effects, preventive principles, and control measures during inspection of work sites. This chapter focuses on previsit preparations, the site visit, and postvisit responses (1,2).
Previsit Preparations
Permission and Appointments
Unless the physician is making an unannounced visit as part of a government or insurance company safety survey, it is always preferable to call ahead and make an appointment with the manager or owner. The physician will seldom be turned down (a cause for suspicion), and most owners are proud to show off their animals, crops, and machines. The manager or owner will want to know the reason for the visit and may advise the physician on basic hazards and safety rules (3).
Proper Attire and Safety Rules
Any physician who visits the agricultural workplace must dress appropri- ately, using proper shoes, clothing, and protection against the elements. He or she should observe all safety rules requiring personal protective equip- ment for the ears, eyes, skin, and hair. Long hair should be pinned up to avoid catching it in rollers with the resultant scalp avulsion injuries.
Women should not wear high or open-toe shoes. It is important for the physician to set an example in the use of safety equipment and following the safety rules.
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The Site Visit
The reasons why a physician should sometimes leave the confines of the hos- pital or clinic and venture out into the agricultural workplace are summa- rized in Table 11.1.
Understanding the Workplace
A physician not familiar with the agricultural workplace may approach the patient’s injuries without knowing the mechanism or agent of injury (see Chapter 25). Some injured workers may not be able to adequately explain how they were injured. A physician who visits the workplace has a greater understanding of the conditions under which the employee works and how the injury occurred (4).
Developing a Working Relationship
The work site visit is also an opportunity for the physician to establish a working relationship of mutual respect with the owner or management, the union, and the employees. Employees are especially impressed to see a physi- cian who will come out to the farm to see what they actually do (5).
Establishing the Tasks for Preplacement Physicals
It is important for physicians who do preplacement or fitness-for-duty exam- inations to know the details of the job for which the employee is being con- sidered. The workplace visit serves to educate the physician regarding the tasks that the prospective employee will be required to perform.
Coordinating Modified Duty and Return to Work
Even workers with serious injuries can be returned to work as long as pre- cautions are taken to ensure that the environment is conducive to the mental and physical healing of the patient. For a physician who sees many injured employees from a particular agricultural work environment, such as a pack- ing shed or processing plant, there is an advantage to going to the workplace
TABLE11.1. Reasons and goals for a workplace visit.
To obtain a working understanding of the work the employee is doing so the physician can understand what the employee is talking about when he or she comes into the office To coordinate a modified duty and early return to work program
To assist in creating a first-aid or rescue program for injured workers
To observe workplace hazards and how the employees are being protected from them To evaluate the veracity of a worker’s claim for injury or disability
and determining in advance which jobs employees with limitations can per- form. The job placements and modifications may be short term or perma- nent, but the goal is to return the worker to a productive capacity and, at the same time, to cut down on the long-term costs of rehabilitation and tempo- rary disability (6).
The mental well-being of the patient may be more important than the physical injuries, and a rapid return to work restores to the injured employee a sense that he or she is once again a breadwinner and is useful to society.
Because low back pain is the most common injury in agriculture, multidis- ciplinary teams have been developed to expedite the patient’s recovery and return to work. A work site visit by a physician or another trained health pro- fessional has been found to be an effective component of such a team approach (7).
Creation of First-Aid and Rescue Programs
Particularly in rural areas remote from cities and city emergency depart- ments, physician visits can be productive in initiating, funding, overseeing, and evaluating first-aid programs. In some countries, a lone physician or clinic is all that is available for injured workers from the fields. In those cases, physician visits to the workplace can help to coordinate first aid, evacuation protocols, and equipment (see Chapter 25).
Migrant Housing
Agricultural health hazards affect not only persons performing the fieldwork but also persons who live in the immediate environment. Migrant workers may live in on-site temporary or dilapidated housing without the basic hygienic requirements dictated by governmental regulations. What might be considered dilapidated temporary housing in some parts of the world might represent the norm in other parts. A useful checklist for assessing the safety and hygienic conditions of worker housing can be found at the U.S. Depart- ment of Labor Web site (http://fortress.wa.gov/esd/portal/employment/
ag/etahousingcheck.pdf ).
Workplace Hazards
The agricultural work site is replete with hazards that result in fatal and non- fatal debilitating injuries or illnesses (see Chapter 3). Proven methods can eliminate or reduce many types of hazards and help identify the causes of an existing health problem (see Chapters 4, 5, and 6). An inspection of the work site by a person who is familiar with the types of work, the work environ- ment, the social environment of agriculture, and the associated risk factors can identify health hazards (8).
A productive agricultural site visit requires fundamental understanding of the potential factors for both chronic and acute injuries. Preprinted checklists provide a comprehensive group of questions to prepare for evaluating a par- ticular work site or injury. You can find appropriate checklists by searching the Internet for “farm and ranch safety audit.”
In addition to typical field and farm activities, agricultural work includes jobs in processing facilities such as canneries and packing sheds. These envi- ronments include aspects that more closely resemble typical industrial and manufacturing environments, except that the various pressures are often dif- ferent, driven in part by maturity of the crop, the impending weather condi- tions, lack of a stable work force, and processing equipment that remains idle for most of the year and draws less maintenance attention than it should (9).
There usually are multiple causes or factors leading to an injury inci- dent. Often the absence of one factor in the series could have prevented the particular incident from occurring. However, correcting all of the con- tributing factors will further reduce the likelihood of a repeated or similar injury (9).
Many insurance underwriters and workers compensation insurance carri- ers have safety information that they utilize and make available to the public.
Organizations such as AgSafe (www.agsafe.org) provide certificate programs and materials that prepare persons to perform hazard identification and con- trol activities as well as other injury and illness prevention plan (IIPP) devel- opment. Enforcement inspections are significantly associated with decreasing compensable workers compensation claims rates (10).
Evaluating the Veracity of Claims
Employers and employees may decide to falsify injuries for their own finan- cial gain. Alternatively, attorneys, government agencies, and insurance carri- ers may have doubts that an injury actually occurred. The treating physician is in a unique position to answer the question of causation by making a work site visit.
Determining how an injury occurred involves asking open-ended questions to elicit more detailed responses in the form of thoughts, observations, and history. The physician should keep in mind the principle of multiple causal factors and should avoid drawing conclusions until after conflicting or incomplete information is resolved as best as possible. However, because much farm work involves lone workers, the specific cause may be difficult to ascertain, especially with deceased or memory-blocked victims. Ascertaining the cause of an agricultural injury depends on finding one of several possi- bilities summarized in Table 11.2 (9).
To determine the veracity of a claim, the physician may best serve the patient by going to the workplace and actually seeing the circumstances of the accident. Sometimes the injury can be reenacted to see if the history related by the patient is plausible (11,12).
Post-visit Actions
The physician needs to write up details of health problems observed in the work-site visit. Appropriate reports, action reports, and memorandums of understanding should record recommendations for hazard abatement, return to duty programs, and modified duty programs. In certain countries and states, specific hazardous conditions, epidemics, infectious diseases, and other problems must be reported to local authorities.
References
1. Cordes DH, Rea DF. Work-site risk assessment. Prim Care 1994;21:267–74.
2. Cordes DH, Rea DF. Workplace visits: an important place in family practice. Am Fam Physician 1994;49:733, 736, 741.
3. Tong DW. Conducting a factory or plant visit. Australas J Dermatol 1995;36:129–32.
4. Gillies RR, Zuckerman HS, Burns LR, et al. Physician-system relationships:
stumbling blocks and promising practices. Medcare 2001; 39(7 suppl): I92–106 5. Kushnir T, Melamed S, Ribak J. Occupational physicians in Israel: work structure,
job and personal characteristics, and job satisfaction. J Occup Environ Med 1997;39:874–81.
6. Noel B, Boillat MA. Reasons for consultation in occupational medicine. Rev Med Suisse Romand. 1994;114:633–41.
7. Karjalainen K, Malmivaara A, van Tulder M, et al. Multidisciplinary biopsy- chosocial rehabilitation for sub acute low back pain among working age adults.
Cochrane Database Syst Rev 2003;(2)CD002193.
8. Wesdock JC, Sokas RK. Medical surveillance in work-site safety and health pro- grams. Am Fam Physician 2000;61:2785–90.
9. Murphy D. Safety and Health for Production Agriculture. St Joseph, MI: Ameri- can Society of Agricultural Engineers, 1992.
10. Baggs J, Silverstein B, Foley M. Workplace health and safety regulations: impact of enforcement and consultation on workers’ compensation claims rates in Wash- ington State. Am J Ind Med 2003;43:483–94.
11. Larsen ME, Schuman SH, Hainer BL. Workplace observation: key to a meaning- ful office history. J Fam Pract 1983;16:1179–84.
12. Lessenger JE. Case Report: Fraudulent pesticide injury: value of a work site visit.
J Agromed 1996;3:27–32.
TABLE11.2. Factors to consider when determining causation of a work-related injury.
A cause-and-effect relationship
Consistency of the mechanism and agents of injury with the description of the injury itself (see Chapter 25)
Internal consistency of the employee’s history
External consistency with the history as related by coworkers
Consistency with what is medically known about the offending substance, machine, animal, infectious agent, or job task
