Bob is 18 years old. He has been working as an electroplater in a small electroplating workshop for 6 months. He uses gloves off and on.

Transcription

1 QUESTION Total Marks: 20 Bob is 18 years old. He has been working as an electroplater in a small electroplating workshop for 6 months. He uses gloves off and on. Electroplating process. Cr 6+ = hexavalent chromium He developed a red flaky itchy rash on both hands about a month ago. He feels it is better when he is away from work. He has never had such a rash before. He is otherwise well and you can find no other signs on physical examination. Question A i. List four likely differential diagnoses for Bob s hand rash. (1 mark) ii. Outline medical investigations and medical management for Bob. (3 marks) Answer A. i. Allergic contact dermatitis chromium or even from latex gloves Irritant contact dermatitis Psoriasis Tinea/fungal infection Endogenous dermatitis/atopic eczema Pompholyx Bacterial infection (primary or secondary) Other reasonable diagnoses may be considered.

2 ii. Investigations Patch testing Perhaps skin scrapings to exclude fungal infection Biopsy?IgE Medical management Avoid/ minimise exposure to likely irritants or sensitisers Education re avoidance of scratching, non-occupational exposures, drying hands, use of soap substitutes, Moisturise Topical steroids Treatment for fungal/ bacterial infection with appropriate agents Dermatology referral May accept alternative statements such as avoidance of latex gloves, avoidance of wet work, avoidance of direct exposure to chromium). Competencies: , Question B i. Assuming the problem is work related, for both potential diagnoses what return to work advice would you give to Bob? (2 marks) ii. What may be potential barriers to successful return to normal duties in this case and setting? (2 marks) Answer B i. If allergic dermatitis, usually not advisable to continue, particularly as he is just starting out in this job. Small exposures can trigger. If he is keen, can try a return to work with maximum precautions and close monitoring. He may need a period of alternative duties to allow dermatitis time to settle. If irritant dermatitis, standard precautions and skin care suitable chemically resistant gloves, regular moisturising, avoid irritants (solvents), wet work. Advise him re regular Health surveillance or return promptly if rash recurs. Even when rash resolves the skin remains sensitive for months to irritants A sensible discussion of the options is required. Some candidate may believe that it would be unacceptable to return him to this environment if allergic

3 contact dermatitis due to Cr exposure is confirmed and may look at alternative options either in this workplace or redeployment. ii. Patient factors o Young immortal non-compliant o High risk of recurrent rash particularly if allergic Workplace factors o Control measures may be inadequate to prevent rash o Use of gloves may itself-> rash (sweating) o Lack of alternative work options Employer factors o Small workplace difficult to modify, accommodate o Lack of $ for controls o Disinterest, keen to get rid of Bob Competencies: You are invited to the electroplating workshop. The employer wants your input in preventing further cases like Bob. Question C Describe the range of control measures that could be considered for chromium electroplating and the method used to confirm that the control of hexavalent chromium at this workplace is adequate. Include in your answer the difference between biological effect monitoring and biological exposure monitoring (4 marks) Answer Hierarchy of controls. Substitution (trivalent chromium), Isolation (automation), enclosures, Engineering local exhaust, balls, foam blankets Administrative (reducing time exposure occurs, health surveillance, attention to hygiene, training re hazards, management of splashes), PPE (gloves, respirator). Will need to demonstrate understanding of the principles of the Hierarchy of Control and specific application to this workplace. Assessing the situation. Personal observation of the workplace (vision, smell), Air monitoring, personal monitoring, health surveillance biological effect & biological urinary exposure monitoring, comparison with best practice. Monitoring: Biological effect is detecting end organ change eg. Spirometry, skin ulcers.

4 Biological exposure monitoring is detecting actual absorption eg. Urine monitoring for chromium Competencies: , You are asked to set up a health surveillance program for chromium for this workplace. You know that chromium is a sensitiser and carcinogen. Question D What key components (types of questions, checks and/or tests) will you include in your health surveillance program in this workplace? Briefly justify for each item why you have included it. (4 marks ) Respiratory questionnaire (asthma, smoking history, upper airway irritation) Spirometry (asthma, pre-existing pulmonary pathology, baseline for future comparison) Skin check (dermatitis, ulcers) Nasal check (irritation, ulcers, septal perforation) Urine monitoring yes/no acceptable but justify, timing of testing (end of shift end of week). May be useful to assess controls. Competencies: , , Question E Who are the relevant parties for communication of health surveillance results and how would you manage communication of the results to each party? (4 marks) The relevant parties are the worker, employer, legislator and possibly the family doctor at the request of the worker. At least three of the above points should be included to obtain Apply confidentiality and privacy principles Obtain appropriate written consent from the worker and explain who will be informed of results Provide worker with his/her results and explanation pitched at his/her level

5 Outcome of health surveillance to be provided to the employer. May also need to provide an explanation of the implications of the results in a verbal or written format and recommendations. Subject to jurisdictional legislation, result especially if abnormal, to be provided to the Regulator e.g. WorkSafe Timeliness and accuracy important Discuss follow up/frequency of testing and storage of results Refer to appropriate specialist if relevant e.g. dermatologist, ENT, respiratory physician Competencies: ,