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Clinical Case Study 2 - Comment


Clinical Case Study in Occupational and Environmental Medicine 

Comment on the bus driver's problem


  • Comment:
This case history relates to a common presentation of a common disease. Unlike the other cases in this series the problem is not as specifically occupational or environmental in its causation. His family history, smoking habits and other lifestyle factors such as his diet were probably very important causal factors.

However other factors could have contributed to his ischaemic heart disease and to that of many others like him, and other important considerations arise:

     
  • What about the evidence that this man's work/ environment may have 

  • contributed to his ill health?
    Contributory causes could include:
     
    • Particulate products of combustion (PM10)
    Epidemiologic research has shown that a 10 microgram per cubic metre increment in PM10 was associated with approximately a 5% increment in emergency hospital admissions for cardiovascular disease such as heart attacks, after adjusting for known confounders. Carbon monoxide and clearly tobacco smoke can be important sources of damage to his heart or vascular system.
  • Occupational stressors
Other researchers have shown associations, probably partly causal, between 
occupational stressors and adverse cardiovascular outcomes.
  • What about the consequences of his ill-health upon his work:- 
    • What information would be needed and what advice should the patient be given about his return to work? 
      Information about the patient's status, about the job requirements and how to link the two is essential. As regards his clinical status, one should check whether he has:

      Anginal symptoms and what provokes them
      Arrhythmias
      Hypertension
      Heart failure

      Public Service Vehicle licences and Heavy Goods Vehicle licences have stringent fitness requirements, and he would not be readily allowed to return to bus driving. In other words fitness for driving his private car is not the same as fitness for vocational driving (eg PSV, HGV). 

      Linking his health status and his job, in summary he would need to be:
      post surgery AND angina free for at least 6 weeks,
      AND
      not hypertensive (BP < 180/100 mm Hg) nor having symptoms of heart failure
      AND
      no dysrhythmia that has caused or is likely to cause incapacity for at least 3 months
      AND
      probably also would have to fulfil other criteria
      eg ejection fraction >0.4
      satisfactory exercise test
       

      Further information and advice should be obtained for example from:
      A Medical Adviser at the Driver and Vehicle Licensing Agency (DVLA) 
      (You can now access the Medical Aspects of Fitness to Drive Online)
      Occupational Health Physician - bus companies should have one
       

  • So what job could he do if he could not drive a bus any more?

  •  

     
     
     

    Perhaps he could be rehabilitated and re-trained in some way? 
    Maybe as a bus inspector?

    Do you have any other thoughts on the management or implications of this case?

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