Download B2B 2017 Environmental Occupational Health J

Back to Basics 2017
Environmental and Occupational Health
Dr. Jennifer LeMessurier MD MPH
PGY4 Public Health and Preventive Medicine
University of Ottawa
Acknowledgements
• This lecture material is based on previous
presentations by Drs. M. Afanasyeva, M.
Maher, B. Pinard, G. Dunkley, R. Spasoff, and
N. Birkett, with material from Dr. A Thompson
Outline
•
•
•
•
Relevant MCC Objectives
Environmental Health
Occupational Medicine
Practice Questions
Part I:
Environmental Health
MCC Objectives: Population Health
Environment 78-6
Rationale:
• Environmental issues are important in medical practice because exposures
may be causally linked to a patient's clinical presentation and the health
of the exposed population. A physician is expected to work with
regulatory agencies and allied health professionals (e.g., occupational
hygienists), where appropriate, to help implement the necessary
interventions to prevent future illness. Physician involvement is important
in the promotion of global environmental health.
MCC Objectives: Population Health
Environment 78-6
Key Objectives:
• Recognize the implications of environmental hazards at both the
individual and population level.
• Respond to the patients concerns through appropriate information
gathering and treatment.
• Work collaboratively with local, provincial and national
agencies/governments as appropriate to address the concerns at a
population level.
• Communicate with patients, communities, and employers, where
appropriate, concerning environmental risk assessment.
MCC Objectives: Population Health
Environment 78-6
Enabling objectives:
• Identify common environmental hazards and be able to classify them into
the appropriate category of chemical, biological, physical and radiation.
• Identify the common hazards that are found in air, water, soil and foods.
• Conduct a focused clinical assessment of exposed persons in order to
determine the causal linkage between exposure and the clinical
condition.
• Describe the steps in an environmental risk assessment and be able to
critically review a simple risk assessment for a community.
• Be aware of local, regional, provincial and national regulatory agencies
that can assist in the investigation of environmental concerns.
• Describe simple interventions that will be effective in reducing
environmental exposures and risk of disease (e.g. sunscreen for sunburns,
insect repellent for prevention of West Nile Virus infection).
• Communicate simple environmental risk assessment information to both
patients and the community.
Environmental Hazards
How are we exposed to environmental hazards?
• Natural and human-made environment
• Types of hazards:
– Chemical, biological, physical
• Reservoirs:
– Air, water, soil, food
• Routes of exposure:
– Inhalation, ingestion, absorption
• Exposure setting:
– Workplace: occupational health (high level exposure, acute or
chronic)
– Outside workplace: environmental health (low level exposure,
chronic)
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Classification of common hazards
Type of
hazard
Examples
Biological Bacteria, parasites, viruses
Health effects
Specific syndromes associated with different agents
e.g., salmonellosis from contaminated food
Moulds
Allergies
Animals
Allergies
Zoonoses e.g., rabies
Chemical Heavy metals
Specific syndromes
e.g., lead poisoning, mercury poisoning
Benzene
Cancers
e.g., acute myeloid leukemia
Carbon monoxide
Asphyxiation
Asbestos
Asbestosis, mesothelioma
Physical
Noise
Hearing loss
(factors that can
harm the body
without
necessarily
touching it)
Radiation
DNA damage leading to cancer
Ultraviolet light
Skin damage, vision loss
Temperature extremes
Hypo- or hyperthermia, heat stroke
Adapted from: http://phprimer.afmc.ca
The most important risk factor for heat-related illness is:
a.
b.
c.
d.
e.
Age over 65
Age under 1
History of prior heat stroke
Low socioeconomic status
Obesity
A 34-year-old woman is brought in from a sporting event
complaining of headache, nausea, and weakness. She had been
jogging outside in sunny weather where the temperature was
35°C with a relative humidity of 70%. She had started a training
program two weeks before. She is hyperventilating, her skin is
moist, and her core body temperature is 38.8° Celsius. She most
likely suffers from:
a.
b.
c.
d.
e.
Sunstroke
Heat cramps
Heat exhaustion
Heat stroke
Heat syncope
Common hazards in the environment
Hazards in:
Examples
Air
Carbon monoxide
Smog
Particulate matter
Water
E. coli
Cryptosporidia
Blue-green algae
Soil
Heavy metals
Petroleum by-products
Food
Listeria
Salmonella
Mercury
Adapted from: http://phprimer.afmc.ca
A 28-year-old woman presents with nausea, vomiting, and
diarrhea. She has no fever. Her history reveals that she
attended a reception about six hours ago. She ate roast beef
with gravy, salad, and had cream-filled pastries for dessert.
1.
Identify the organism responsible for her symptoms:
2.
Prevention of this food-borne illness could have been achieved by:
a. Freezing the food
b. Heating the food to 140° Fahrenheit
c. Proper hand washing by food handlers
d. Proper cleaning of contaminated surfaces
e. Control of flies
Taking an Environmental History
• Clues that illness is caused by environmental factors:
– Patient suspects it
– Illness pattern is atypical (absent usual risk factors,
unusual age group or course, no response to
treatment)
– Temporal pattern of illness (weekends/weekdays,
holidays/home)
– No obvious other cause
– Signs/symptoms suggest specific agent
14
Adapted from: http://phprimer.afmc.ca
Components of an Environmental History
(CH20PD2)
• Community: neighborhood sources of hazard; industry, waste
storage
• Home: year of construction, renovations; materials used in
construction and decoration; moulds; garden and house plants; use
of cleaning products, pesticides, herbicides
• Hobbies and leisure: exposure to chemicals, dusts, or microorganisms
• Occupation: current and previous occupations; longest occupation;
work with known hazards; air quality; use of PPE
• Personal habits: hygiene products; smoking; recreational drugs
• Diet: sources of food and water; cooking methods; food fads
• Drugs: prescription, non-prescription, and alternative
(naturopathic, Ayuverdic); health practices
Adapted from: http://phprimer.afmc.ca
Focused Environmental History
• If a scanning question reveals a possible hazard, ask detailed
questions about the nature and level of the hazard and then check:
• Time: When did symptoms begin? When did exposure begin? When
do symptoms get worse? When do they improve?
• Place: Where is the patient when symptoms get worse? Where is
the likely hazard? What is the channel through which the hazard
reaches the patient?
• Person: Does anyone else have similar symptoms? Who? When?
Where?
Adapted from: http://phprimer.afmc.ca
What is an Environmental Risk
Assessment?
• Process of evaluating the likelihood of
occurrence and probable severity of health
effects due to a hazard
• Conducted by: occupational health agencies,
environmental protection agencies, public
health authorities, specialist clinicians
How do we assess a health risk?
Hazard
Risk is determined by the
characteristics of the hazard,
whether or not an exposure
has occurred, and the
degree of susceptibility
Risk
Exposure
Susceptibility
Steps in Risk Assessment
Hazard identification:
Identifies the agent responsible for the problem, its adverse effects, the target population, and
the conditions of exposure*
Hazard (risk) characterization:
Describes the potential health effects of a hazard and answers the clinician’s question about
whether the identified hazard could possibly cause the patient’s symptoms.
• Dose-response
• Toxicology
Exposure assessment:
Quantifies the exposure of a person or population to a hazard through direct measurements or
through estimation*
Magnitude, frequency, duration, route, etc.
Risk estimation:
Quantifies the likelihood that a hazard will affect a specific person or population as well as the
size or severity of the effect.
• Individual level: How much has the hazard contributed to the patient’s condition?
• Population level: How much extra risk of the condition in the population is attributable to the
exposure?
*The environmental history informs these steps
Adapted from: http://phprimer.afmc.ca
Hazard Identification
Workplace Hazardous Material Information System (WHMIS)
Canada's national hazard communication standard; the
key elements of the system are:
• Hazard classification
• Labelling of containers
• Provision of (material) safety data sheets [(M)SDS]
–
–
–
–
–
Identification: for the product and supplier
Hazards: physical (fire and reactivity) and health
Prevention: steps to reduce or prevent exposure, or in an emergency
Response: appropriate responses in various situations (e.g., first-aid)
http://www.ccohs.ca/oshanswers/chemicals/whmis_ghs/sds.html
• Provision of worker education and training programs
WHMIS 2015 Pictograms
Not adopted in
WHMIS 2015
21
Hazard Identification
International Agency for Research on Cancer (IARC)
• Group 1
Carcinogenic to humans (117 agents)
– Arsenic, asbestos, benzene, diesel engine exhaust, radon, processed
meat, tobacco smoke
• Group 2A Probably carcinogenic to humans (74 agents)
– Red meat, cisplatin, shift work
• Group 2B Possibly carcinogenic to humans (287 agents)
– Coffee, welding fumes
• Group 3
Not classifiable (503 agents)
– Magnetic fields, fluorescent lighting
• Group 4
Probably not carcinogenic to humans (1 agent)
– Caprolactam
Risk management
• Interventions to manage the risk of common
environmental hazards:
– Carbon monoxide: CO home detector
– Salmonella: well-cooked poultry and eggs, safe food
handling
– Listeria: avoidance of unpasteurized cheese for
pregnant women
– West Nile Virus: clothing, insect repellent (DEET)
– UV light: sunscreen, sunglasses, shade, hat, long
sleeves
– Radon: ventilation, air exchanger, radon test kits
Risk Communication
• How we facilitate understanding of a
particular risk, and inform how to take action
to reduce that risk
UV Index
Image from: http://www.who.int/uv/intersunprogramme/activities/uv_index/en/index1.html
Image from: https://www.on.lung.ca/document.doc?id=1722
Penetration of particulate matter
The Lancet 2014 383, 1581-1592
Risk Perception
Risk = Hazard + Outrage
• Factors increasing perception of danger:
– Characteristics of exposure:
• Involuntary; not under personal control
• Unnatural; unfamiliar
• No trust in institution involved; media attention
– Characteristics of outcome:
• Catastrophic (not chronic); immediate; irreversible
• Unknown, uncertain outcome, dreaded outcome
• Affect children or identifiable people
Environmental Health Jurisdiction
– Local (or Regional) Public Health
• Enforcement of water and food safety regulations, sanitation, local hazard
assessment, reportable diseases
– Municipal
• Garbage disposal, recycling, water distribution
– Province/territory
• Toxic waste disposal, air/water standards
• Ontario Ministry of the Environment (monitors air quality across ON)
– Federal
• Health Canada - food regulations, designation and regulation of toxic substances
• CFIA (Canadian Food Inspection Agency) – enforcement of regulations
• Environment Canada - The Asbestos Mines and Mills Release Regulations
– International
• Multilateral agreement (Kyoto Protocol)
•
Whom to Consult?
• Local public health - Ottawa Public Health (613) 580-6744 – environmental exposures
• Ontario Ministry of Labour – occupational hazards
• Poison Control Centre – specific toxicants
• Motherisk – effects on fetus
Part II:
Occupational Medicine
MCC Objectives: Population Health
Work-related health issues 78-8
Rationale
• Workplace health and safety hazards can contribute to many different health
problems. Physicians play an important role in the prevention and management of
occupational injury, illness and disability.
Causal Conditions (list not exhaustive)
• Ergonomic hazards (e.g. awkward postures and movements, poor lighting)
• Chemical hazards (e.g. organic solvents, metals, asbestos, toxic gases)
• Physical hazards (e.g. noise, vibration, radiation)
• Biological hazards (e.g. blood or other body fluids, animal and bird droppings)
• Psychological and work organization hazards (e.g. workplace stressors, workplace
bullying)
Key Objectives
Given a patient with a health problem, the candidate will evaluate the possible
workplace etiological factors, to assess the contribution of occupational exposures for
the most common pathologies, to assess the impact of the condition on the ability to
work, and develop an appropriate management plan. Particular attention should be
paid to the identification of occupational risks for the patient and his/her co-workers.
MCC Objectives: Population Health
Work-related health issues 78-8
Enabling Objectives
Given a worker with a health problem, the candidate will
1.
list and interpret critical clinical findings, including:
a.
perform a history and focused physical examination to identify the illness and determine the possible
relationship of symptoms to work;
b.
identify hazards in the workplace that could have had an impact on the health problem (work and
exposure history);
c.
identify protective equipment being used and environmental controls that are in place;
d.
identify non occupational factors that could influence the condition.
2.
list and interpret critical investigations, including:
a.
appropriate laboratory or radiologic investigations depending on the presenting health problem (e.g.
chest radiography, ultrasound);
b.
physiologic and/or functional assessments (e.g. PFTs , audiograms, occupational therapy assessment).
3.
construct an effective initial management plan, including:
a.
initiate specific therapy as required for the health problem;
b.
determine whether the patient should be assigned to a different work, or stop work and advise the
patient on this topic;
c.
determine follow up care and whether further consultation, counselling and/or a multi-disciplinary
approach to care is needed;
d.
advise the patient on workers compensation;
e.
advise the relevant authorities if necessary (notifiable disease, reporting a dangerous situation).
Occupational Medicine (OM) in MCCQE Part 1
• As a primary question
• Integrated into options for other questions
• Think about classic occupational skin and lung issues
• Also think about other domains in which OM can play a role,
such as psychiatry, and also specific conditions which have
occupational causality such as abnormal liver
enzymes/function tests, fatigue, hypertension etc.
Types of clinical scenarios that may involve
occupational exposure
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Cough
Hand and wrist injuries; overuse tendinopathies (DeQuervain’s tenosynovitis)
Numbness / tingling / altered sensation
Fatigue (shiftwork; CO exposure)
Allergic reactions and atopy (occupational asthma)
Altered hemoglobin levels (anemia in lead poisoning)
Syncope and pre-syncopy (heat)
Dysmenorrhea
Proteinuria
Sleep disorders
Bone or joint injury
Back pain
Neck pain
Poisoning
Prenatal care
Some examples of occupational diseases
Common, non-specific work-related diseases include dermatitis, asthma, and
musculoskeletal disorders.
Condition
Agent
Example of at risk occupation
Berylliosis
Beryllium
Aerospace industry
Byssinosis
Cotton dust (numerous agents) Cotton industry
Farmer’s lung
Mould in hay
Farming
Asbestosis,
Mesothelioma
Asbestos
Demolition work; shipbuilding
Hepatitis A
Hepatitis A virus
Sewer workers
Silicosis
Silica dust
Stone workers
Adapted from: http://phprimer.afmc.ca
Occupational Health as a Public Health Concern
• Work-related injuries include injuries, illnesses,
diseases or disabilities resulting from work-related
accidents or exposure to a noxious substance.
• Most of the world’s population spend 1/3 of their
adult life at work
• In Canada:
– 920 workplace deaths in 2001; 919 in 2014
– 1 of 68 employed workers in 2010 was
injured/harmed on the job and received workers
compensation as a result
This material is courtesy of Aaron Thompson, MD, MPH, FRCPC
Occupational Health Outcomes
• The most significant chemical exposures tend to be solvents
and heavy metals:
– Most solvents cause CNS depression, irritation and
dermatitis
– Some solvents causes PNS, hepatic and/or renal toxicity
– Heavy metals primarily cause CNS, PNS, haem, and renal
toxicity
This material is courtesy of Aaron Thompson, MD, MPH, FRCPC
Occupational Health Outcomes
• Many chemical and biological exposures can cause
allergy resulting in:
• Asthma (occupational or work-exacerbated)
– 18% of asthma is work related
– If true allergy – sensitizer-induced asthma (vs. irritantinduced asthma)
– Skin prick testing (immediate hypersensitivity type I)
• Allergic contact dermatitis (vs irritant contact
dermatitis)
– Patch testing (delayed hypersensitivity type IV)
This material is courtesy of Aaron Thompson, MD, MPH, FRCPC
Occupational Health Outcomes
• Approximately 10% of all cancers are occupational
– Common occupational cancers are lung, bladder,
and mesothelioma
– Common occupational carcinogens are asbestos,
polyaromatic hydrocarbons (PAHs), and aromatic
amines
This material is courtesy of Aaron Thompson, MD, MPH, FRCPC
Some classic occupational
exposures
Asbestos
•
Pulmonary fibrosis (asbestosis) – exertional dyspnea and bibasilar endinspiratory rales
•
Localized and diffuse pleural thickening, rounded atelectasis, mesothelioma,
and lung cancer; may be associated with cancer at extra-thoracic sites
•
Most important route of exposure is inhalation
•
Miners, shipbuilding facility workers, demolition worker
•
Asbestos in the air adheres to work clothing, even if the clothes are brushed
•
Cleaning of clothes at home liberates asbestos fibers and has been shown to
cause cancer in family members (para-occupational disease)
Which of the following diseases is found almost
exclusively among persons who have worked
with or have been exposed to asbestos?
a. Bronchogenic carcinoma
b. Byssinosis
c. Pleural mesothelioma
d. Laryngeal carcinoma
e. Emphysema
Noise-induced hearing loss
• High-frequency sensorineural loss
• Usually is similar in both ears
• Hearing is relatively normal between 250 -1,000 Hz (the loss at the
low frequencies rarely exceeds 40 dB)
• “Noise notch” between 3000-6000 Hz, typically centered at 4,000
Hz (which rarely exceeds 75 dB)
• Recovery at the higher frequencies of 6,000-8,000 Hz
• Word recognition is fairly good ( > 75%)
Work-related health issues:
Prevention
• Primary prevention
– Preventing the onset of disease by altering behaviours or
exposures that can lead to disease, or by protecting
against the effect of exposure to a disease agent
– Achieved using hierarchy of controls
• Elimination
• Substitution
• Engineering
• Administrative
• Personal Protective Equipment (PPE)
This material is courtesy of Aaron Thompson, MD, MPH, FRCPC
Conceptualizing the control of occupational risks
Source
Path
Receiver
Potential approaches to risk control
Eliminate
Modify
Redesign
Substitute
Relocate
Enclose
Engineering controls:
Absorb, block, dilute,
ventilate
Administrative controls:
Regulate exposure
duration
Enclose
Protect
Relocate
PPE
Work-related health issues:
Prevention
• Secondary prevention
– Preventing the establishment or progression of a disease
– Examples
• Screening to detect disease at an early stage when
intervention may be more cost-effective
• Medical surveillance
This material is courtesy of Aaron Thompson, MD, MPH, FRCPC
Work-related health issues:
Prevention
• Tertiary prevention
– Preventing the return of a disease that has been
treated in its acute phase. It seeks to limit or
delay the impact caused by the disease on the
patient’s function, longevity, and quality of life.
– Examples
• Disability management
• Return to work
This material is courtesy of Aaron Thompson, MD, MPH, FRCPC
Work-related health issues:
Prevention
• 1o prevention
– Minimize Exposure, prevent Outcome
– Approach using hierarchy of controls
• 2o prevention
– Early detection of Outcome
– Screening, surveillance
• 3o prevention
– Mitigate effects of Outcome
– RTW +/- accomodation once effectively treated and controls
have been put into place to prevent recurrence
This material is courtesy of Aaron Thompson, MD, MPH, FRCPC
Applying the principles of prevention:
Worker exposed to lead at a battery recycling plant
• 1o prevention
– Substitute tin for lead
– Enclose process, increase ventilation
– Optimize hygiene – no eating/drinking/smoking,
separate clothes, shower post shift, housekeeping
– Fit tested lead cartridge respirator
• 2o prevention
– Surveillance: annual Hx, physical, CBC, blood lead level (BLL)
• 3o prevention
– Chelation if indicated
– RTW when BLL acceptable and control measures in place
Lead:
Applying the Environmental/Occupational History
• Occupational: manufacturing or use of batteries, pigments, solder,
ammunitions, paint, car radiators, cable and wires, some cosmetics,
ceramic ware with lead glazes, tin cans
• Significant exposures in primary and secondary lead smelting and
refinement
• Hobbies: distillation of "moonshine" alcohol; home repairs; shooting at
gun ranges (bullets have lead, particularly home-made)
• Lead-glazed tableware and cookware; ceramic dishes (pottery)
• Ayurvedic medicines, herbal medications, recreational drugs
Lead:
Health Outcomes
Blood levels are elevated if ≥ 10 μg/dL =
0.48 μmol/L
Main burden in adults is due to
• Neurological effects (both CNS
and PNS)
• Hypertension
• Short-term (< 1 year)
–
–
–
–
–
–
–
–
–
Spontaneous abortion
Reduced birth weight
Postnatal developmental delay
Nonspecific symptoms
Neurocognitive deficits
Encephalopathy
Sperm abnormalities
Anemia (basophilic stippling)
Colic
• Additional long-term (> 1 year)
–
–
–
–
Hypertension
Nephropathy
Peripheral neuropathy
Gout
Lead:
Management
• Eliminate the exposure
• Education
• Chelation is considered if ≥ 50 μg/dL
Occupational Health Conditions:
Clinical Assessment and Management
• Confirm diagnosis, then address work relatedness
– Work description and occupational profile
– Prior and current exposure to hazards
– Review of relevant workplace (materials) safety data
sheets [(M)SDSs)]
– Depending on the condition, there are various objective
means to determine work relatedness
• Prescribing return to work (with restrictions if necessary) is
part of the treatment plan
• If unsure, refer! (Occupational Medicine Specialist)
This material is courtesy of Aaron Thompson, MD, MPH, FRCPC
Medico-Legal Aspects
• 90% of workers are under provincial jurisdiction
• 10% of workers are under federal jurisdiction: 16 federallyregulated industries (e.g. banks, airports, highway transport)
– under Canada Labour Code
• Ontario: Occupational Health and Safety Act
– Enforced by Ministry of Labour (inspectors)
– Employers
• must protect health and safety
• report workplace illnesses and injuries
• accommodate injured/ill workers
• pay cost of injury, illness
• Compensation is tied to province of work, not province of residence
Workplace Safety and Insurance Act
(Ontario)
• Establishes WSIB to oversee work-site
injuries/disease
• Funded by employers only
• Non-fault protection but no right to sue
• MD must submit medical report to WSIB (if
WSIB requests); no need for patient waiver
Ergonomics examines ways to adapt the working
environment to ensure a safe and productive
workplace. Which of the following factors is the
most important to improve the physical design
of a sedentary job?
a. Maintaining a static position
b. Maintaining a standing position
c. Eliminating the waist motion
d. Installing a soft floor
e. Maintaining a static holding position
“Duties” of the treating physician
•
Treat worker and assist in RTW process
•
File Worker’s Compensation claims
•
Report to Ministry of Labour if designated substance has resulted in disability
•
CMA Policy 2000
•
–
Be knowledgeable of workplace
–
Draft clear recommendations
–
Make use of available occupational health resources
Occupational Health Physician assumes lead in advising on RTW/accommodation
This material is courtesy of Aaron Thompson, MD, MPH, FRCPC
59
This material is courtesy of Aaron Thompson, MD, MPH, FRCPC
This material is courtesy of Aaron Thompson, MD, MPH, FRCPC
Practice Questions
Which one of the following is not a
typical feature of asbestosis?
a) increased risk of cancer
b) pleural thickening and calcification
c) interstitial fibrosis
d) obstructive pattern on pulmonary function tests
e) none of the above
The following statements regarding noise are
true EXCEPT:
a) temporary threshold shift recovers following
cessation of noise exposure
b) permanent threshold shift is characterized by a
progressive pattern of hearing loss
c) most cases of permanent threshold shift are
surgically treatable
d) higher frequency noise is more damaging than
low frequency noise
e) none of the above
Lead exposure typically results in:
a) chronic dermatitis
b) resting and intention tremor
c) extensor muscle weakness
d) arrhythmias
e) cerebellar ataxia
Which of the following statements concerning the
Worker’s Compensation Act is true?
a) the worker reserves the right to sue the
employer for negligence
b) funding is provided by the provincial government
c) the worker is guaranteed payment from the first
day of injury/illness if it is deemed to be workrelated
d) the Worker’s Compensation Board is an
independent, private agency
e) none of the above
Which of following statements regarding
radiation is false?
a) natural background radiation accounts for about
half of a typical person’s exposure
b) ionizing radiation causes intestinal villi to
become denuded
c) exposure to non-ionizing radiation may result in
cataracts
d) ionizing radiation results in an increased
incidence of neoplasia such as lung and thyroid
e) none of the above
Which of the following statements concerning
exposure to solvents in the workplace is
true?
a) each solvent compound has a specific antidote
that can be used to treat exposure
b) a prominent symptom of solvent exposure is
memory loss
c) some solvents can cause skin dryness and loss
of subcutaneous adipose tissue
d) solvents do not affect the bone marrow
e) all of the above
Which one of the following gases is NOT
irritating to the respiratory tract?
a) ozone
b) sulfur dioxide
c) hydrogen chloride
d) carbon monoxide
e) chlorine
How much radiation is an "average Canadian adult
woman" typically exposed to each year from the
following sources: background dose; one screening
mammography, and one abdominal CT scan?
a) Background 0.1 Sv; mammography 0.5 Sv; CT 1.0 Sv.
b) Background 1.0 Sv; mammography 0.5 Sv; CT 0.1 Sv.
c) Background 1.0 mSv; mammography 50.0 mSv; CT 5.0 mSv.
d) Background 2.0 mSv; mammography 3.0 mSv; CT 10.0 mSv.
e) Background 1.0 mSv; mammography 0.1 mSv; CT 0.1 mSv.
More MCQs
• Here are some more questions you can use to
test your knowledge:
http://www.medicine.uottawa.ca/sim/data/Selftest_Qs_Environmental_e.htm
• (The questions contain comments on the
answers, to illustrate why a given response is
not correct)
Resources for practice
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MSDS are available on the web: http://www.hc-sc.gc.ca/ewh-semt/occup-travail/whmis-simdut/indexeng.php
List of diseases reportable to the medical officer of health (and the reporting form):
http://app06.ottawa.ca/online_services/forms/health/support/professionals/communicable_disease/for
m_en.pdf?redirec=no
Ottawa Public Health is available 24/7 (613 580-6744)
List of regulations by Environment Canada:
http://ec.gc.ca/lcpe-cepa/eng/regulations/detailReg.cfm?intReg=56
Check your local AQI and refer your patients to this site:
http://www.airqualityontario.com/reports/summary.php
Occupational Medicine Specialists of Canada: http://www.omsoc.org
Case studies in Environmental Medicine: http://www.atsdr.cdc.gov/csem/csem.html
Lange CURRENT Occupational & Environmental Medicine: Fourth Edition Joseph LaDou McGraw Hill
Professional, Oct 23, 2006
Call Poison Control Centre 24/7 for all questions regarding toxicants (you can always ask to speak to a
physician – toxicologist)
Call and refer patients to Motherisk for all questions regarding exposures during pregnancy
Questions about chemical spills – call CANUTEC