Presentation by Dr James Douglas, GP in Fort William, Scotland.

1. Occupational Health in Rural
General Practice
Dr James Douglas,
Tweeddale Medical Practice,
Fort William, Scotland.UK

2. Occupational Health in Rural
Practice
• Agriculture
• Aquaculture
• Food processing
• Forestry
• Tourism
• Outdoor Education
• Diving
• NHS/ Local Government / Utilities

3. Occupational Health as a GP in Fort William
Fish Farming
Diving Medicine
Research
Occupational Asthma
Salmon Processing

4. Laggan Dam Lochaber Aluminium Smelter
Power House Cell Room

5. Principles of Occupational
Health
• Is this illness or symptom caused or
aggravated by the job?
• Will this patients illness affect their job
and the safety of others?

6. Is this illness or symptom
caused or aggravated by the
job?
• Occupational asthma / dermatitis
• Occupational Deafness / Vibration Illness
• Musculoskeletal Injury
• Bladder Cancer / Mesotheiloma
• Poisoning – lead, CO,methane,H2S
• Zoonosis in rural populations
• Infection in NHS

7. Will this patients illness affect their job
or the safety of others at Alcan?
• Hot Metal Work
– heat stress and unexpected incapacity
• Pot Room Asthma
– Hydrogen Fluoride

8. Will this patients illness affect their job
or the safety of others at Alcan?
• Hydro and Estates
– lone working and remote accidents
• COMAH designation and local community
safety

9. Will this patients illness affect
their job or the safety of others?
Clinical work done by all GPs
• Unfit to work – med 3 certificate
• Return to work – ? phased return plan
• Chronic Disease Management
– keeping the population at work and in health
• Risk assessment of medication or illness
- likelihood and consequence
• DVLA HGV/PSV medical standards

10. Occupational Health Information
www.hse.gov.uk

11. Occupational Health
in Agriculture and
Aquaculture
Machinery, weather, lone working
Disease in the stock and their
treatments
Pesticides
Inhalation of particles
Economic pressure of the market

12. Occupational Health in
Salmon Farming and Processing
2000 rural jobs in Scotland Multi national industry
concern for the environment Norway , Chile,
Canada, Tasmania

13. Hard work on a fish farm

14. Sea Lice and Furunculosis

15. Where does the pesticide go?
Acute and Chronic OP poisoning evidence and opinion

16. Fish Farmers PPE for
Organophoshates

17. Salmon Immunisation
to prevent Furunculosis
Aeromonas Salmonitica

18. Needle-stick injury from
oil based vaccine

19. Rural GP and their community
• Visibility , geographically defined
population
• “ BA chest” in Inverlochy 1980s as a
young GP
• COPD in short retirement
• Sheep Dip in crofters and neurological
effects
• Previous recession and new industry for
rural Scotland – salmon farming and
processing

20. Salmon processing causing
occupational asthma

21. Occupational Asthma
clinical history
• Asthma caused or aggravated by work
• Symptom patterns vary with work in the
early stages
• 2 weeks to 6 months onset
• Early diagnosis essential for individual
and whole workforce
• Chronic phase diagnosis difficult

22. RESEARCH METHODOLOGY
• CROSS SECTIONAL SURVEY
to identify cases against a diagnostic
standard
• CASE CONTROL STUDY
to determine why patients get the disease
• Compare and contrast
cases and “non cases”
( controls from the same factory)
• Smoking / Atopy / Place of work/ Age /sex
• Has engineering modification worked?
• The company still need to process and
sell fish!

23. Why the GP ?
surely this is a specialist
area and covered by too
much Health and Safety
activity already!
• Local knowledge of patients and work
• No chance in diagnosis without the
GP being open to the diagnosis
• Interesting and about simple clinical
care of patients

24. Sport Diving in UK
• British Sub Aqua Club , Scottish Sub Aqua
Club, PADI worldwide franchise.
• Some Sport Diving Instructors can be
classed as professional divers by HSE
• Underwater Archaeology and Scientific
Diving has its roots and training systems
from sport diving but classed as
professional
• Clam divers on the margins!

25. SPORT DIVING and DIVING SAFETY
10-12 UK fatalities per year , 50 episodes of decompression illness
Diving in pairs for rescue
Training with increasing challenge from shore dives to wreck diving in
Scapa or West Coast - SSAC or BSAC club systems best for safety

26. Sport Diving on Thesis Wreck Sound of Mull
with Scottish Sub Aqua Club
30 meters depth , cold water, nitrogen narcosis , tides ,boat cover
- training and dive planning for safety

27. Heat Loss and Hypothermia

28. Descent Phase of Dive

29. Ascent phase of Dive
Cerebral Arterial Gas Embolism

30. Ascent phase of dive
Pulmonary Barotrauma
• Interstital
Emphysema
• Pneumothorax
• Underwater blast
injury
• Training
• Medical
Screening

31. Ascent phase of dive
Decompression Sickness Type 1&2
Acute Decompression Illness
• Dissolved nitrogen
comes out of
solution during
ascent after single
or multiple long ( >
30 minutes) deep
dives ( >25 metres)
causing bubbles in
the blood and CNS
”the bends”
Lemonade analogy for the bends

32. Ascent phase of dive
Acute decompression Illness
“The bends”
• An acute neurological
emergency
– the spinal cord and
brain are at risk of
permanent damage
• Multilevel spinal cord
motor and sensory signs –
cant walk or balance
• 100% Oxygen and
transport to chamber by
road or helicopter after
discussion with
recompression chamber
Diver decompressing in water using
wrist computer

33. Ascent phase of dive
Acute Spinal Decompression Sickness

34. Physical Signs in
Neurological Decompression Sickness Affecting Spinal Cord
Girdle pain
Motor and proprioception deficit
Urinary retention
Evolving multi site spinal haemorraghe
Minutes matter!
Entirely a clinical diagnosis
– don't delay with scans in A&E

35. Treatment of Acute Decompression sickness
Breathing 100% O2 for
periods at depth

36. The diving emergency
• Accurate history of depth, times and pattern
of collapse post dive helps decide bends or
barotraumas for treatment plan.
• On scene - give 100% oxygen, oral fluids,
aspirin, exclude rare pneumothorax
• “999 Coastguard”
- for evacuation and communication
• Aberdeen Royal Infirmary –01224 681818
ask for Duty Diving Physician for advice

37. Summary of Occupational Health
in Rural Practice
• Care of a community
• Visibility of new things and problems
eg John MacDonald and tagging calves
Iain MacNicol and Glensanda
• You are likely to be the only person with
knowledge skill and insight
• Rare diagnosis
• Just do it and be confident in yourself!