Second Nature--An Injured Adolescent

An Injured Adolescent

MCP Hahnemann University
Philadelphia, Pennsylvania
Instructor(s): Bresnitz, Eddy A.; Paranzino, Grace; Rubenstein, Harriet; Vaught, Wayne
Subject area: Health / Medicine
Department: Medicine
Level: Undergraduate Medical
Cost/equipment needed: The actual case
Learning objective: Develop Individual Skills, Provide Information
Teaching style: In-class Activity

Please note that the copyright for this course project is retained by the instructor.

This case study describes a 14 year old boy who presents with a cut he received while cleaning a power mower at work. In the case, students identify work hazards and their potential health effects, discuss prevention strategies, and explore legal and ethical issues. The case is used with medical students and residents at MCP Hahnemann University.

Student and Facilitator's Guide

Michael Byron is a 14 year old who comes to your office with his mother several days after cutting his right arm while cleaning a power mower. His mother noticed the cut this morning. She is concerned that he needs a tetanus shot, and that the area is starting to look infected. Mike explains that he is working this summer for a local landscaping company.

You ask Mike what he does at work. He tells you that he does "...a little bit of everything. I mow, trim hedges, spray, do some tree work, weed, and do whatever my boss tells me to do."

1. What are some hazards Mike might face at work? What are their potential health effects?
2. How would you advise Mike to protect himself from these work hazards?
3. What immunization issues should be addressed?

Information for Facilitator:

1. In the landscaping business, employees (including adolescent workers) are potentially exposed to a variety of occupational and environmental hazards. Some common hazards and their associated health effects are listed in Table 1.

Potential health effects from these hazards will vary depending on type and length of exposure, and any pre-existing medical problems. As with adults, hazardous exposures on the job may produce acute or chronic health effects in the working teen. For example, depending upon the nature, duration, and level of exposure, working with pesticides may result in acute pesticide poisoning. Long-term exposure may result in chronic health effects. it is important to keep in mind that exposures may take years or several decades to product their deleterious health effects, and it is not yet known how exposure during adolescence to hazards with long latency periods affects the incidence of disease and illness in adulthood.

2. Primary prevention measures focus on reducing the source of exposure. Redesign of work methods might allow for minimizing the use of specific equipment. When a particular source of exposure cannot be eliminated, engineering controls (enclosing, isolating the source) and administrative controls (development of procedures prohibiting eating or smoking in work areas, work scheduling - limiting time a worker spends with a potential exposure), and work practices (education and training programs, use of personal protective equipment) should be implemented in order to reduce the exposure. Secondary prevention measures include encouraging workers . report symptoms, injuries, and illnesses to their employer and physician.

Mike should be aware of chemicals used during work. Material Safety Data Sheets (MSDSs) should be available to workers and can be obtained from the employer and the product manufacturer. The MSDS describes the acute and chronic health effects, flammability, physical properties, chemical and trade names, emergency procedure(s), special protection information, and precautions for proper storage. The content of MSDSs varies in quality and may not provide supplemental information on the combined or synergistic effects of multiple chemical exposures.

3. Booster immunization with diphtheria and tetanus toxoid (Td) should be administered every 10 years. Children immunized according to the recommended ACIP schedule should receive the first booster at age 14 to 16.

You ask Mike whether he has working papers. His mother abruptly responds, "We don't want to make a big thing out of this. He's working under the table and it keeps him busy. He's working with some of his school friends, getting some experience, and to be honest, we really can use the money."

4. What legal and ethical issues does this situation raise for you? 4a. Are there child labor laws that apply?

4b. What are your responsibilities as a physician?

Information for Facilitator:

4. and 4a. The primary federal law governing the employment of workers under the age of 18 is the Fair Labor Standards Act (FLSA). Individual states may also have child labor laws, and where the provisions of these laws are in conflict with those of the FLSA, the stricter standard applies. The FLSA regulates the number of hours youth may work daily and weekly, sets minimum ages for general and specific types of work, limits work during morning and night hours and prohibits young workers' participation in specific occupations and activities. Many states (PA and NJ) require minor workers to obtain employment certificates, also known as "working papers" or "work permits", from school authorities prior to employment, in an effort to assure that employment does not compromise the young workers' health, safety, or academic performance. In PA and NJ, working papers can be obtained from schools, guidance counselors, township administration buildings, and libraries. The document must be completed by the school official, the employer, a parent or guardian, and one of several specified health care providers.

The patient in this scenario is working without an employment certificate in violation of state law. Operating a power mower is in violation of the FLSA. Furthermore, if "doing some tree work" involves climbing ladders, then the patient is engaged in an activity that is prohibited under PA child labor standards. The physician is not required to report these violations, and in fact, in the absence of such a legal requirement, various codes of ethical conduct admonish the physician to maintain patient confidentiality unless there is an overriding public health interest to the contrary. In this case, the physician has several options:

Report the employer to the PA Bureau of Labor Standards (placing the patient's continued employment in jeopardy),
Counsel the patient and his mother regarding the hazards of his work,
Urge the patient to refuse to perform the prohibited activity and to obtain the appropriate protective measures and devices from the employer to prevent exposure to other hazards,
Urge the patient and his mother to counsel his co-workers and their parents about the illegal and unsafe working conditions.

4b. The patient's mother implies that you should not disclose information regarding the minor patient's employment status. Generally, information obtained during a patient interview is to be kept confidential. The extent to which a physician may keep such information confidential should be guided by ethical and legal concerns. Ethically, the physician may be justified in revealing patient information in order to protect the health and safety of others.

Physicians should be aware of occupational exposures that may pose an increased health risk to their patients. Adolescent workers are likely to be inexperienced and unfamiliar with job tasks and their potential hazards, as well as their rights on the job. Patients need to be able to make an informed decision regarding the acceptability of occupational hazards. In this case, being sure that the parents, and the patient understand the potential occupational health risks as well as ways to minimize or prevent risks are key elements necessary for this patient interaction.

Physicians should advise their adolescent patients who suffer a work-related injury or illness that they may have the right to receive workers' compensation for medical expenses and lost wages arising out of the injury or illness. The fact that an adolescent is working illegally does NOT affect his/her right to compensation. In Mike's case, because there was no lost time related to the injury, he would only be entitled to recover his medical expenses. Physicians and health care professionals therefore have the responsibility to educate their minor patients and parents about their health and safety, and workplace rights and responsibilities.

Table 1 Hazards Encountered in Landscaping Work and Their Health Effects
.

HAZARD/EXPOSURE	POTENTIAL HEALTH EFFECT(S)
1. Falls from ladders, walls, etc.	Sprains and strains, fractures, dislocations, temporary or permanent impairment
2. Cutting tools, powered and non-powered tools, sharp objects	Cuts, lacerations, infection, amputation, physical impairment
3. Pesticides Organophosphates (most common) Parathion Malathion Dursban Carbamates Sevin	Headache, sweating, n/v, dizziness, tremor, incoordination, skin rash, blurred vision, salivation, coma, CNS effects, cancer, productive/developmental effects Abdominal pain, n/v/d, headache, sweating, salivation, blurred vision, fasciculations, CNS effects, cancer
4. Poison oak, ivy, sumac	Allergic contact dermatitis, irritant contact dermatitis
5. Petroleum distillates Fuel oil Gasoline Lubricating oils (solvents)	Burning in chest, headache, n/v, dyspnea, tachypnea, confusion, CNS depression
6. Ergonomic hazards (repetitive motion, use of tools & equipment designed for adults, overexertion)	Musculoskeletal injuries/illnesses, back pain, irritation of joints, sprain/strain
7. Ozone/particulate matter	Nose, throat, eye irritation, asthma and bronchitis
8. Noise from power equipment	Temporary or permanent hearing loss
9. Excessive heat	Heat-related illnesses: heat stress, heat stroke
10. UV radiation	Sunburn, skin cancer, cataracts
11. Power machinery exhaust	Burns, carbon monoxide exposure, kidney cancer, headache, ataxia, dizziness, lethargy, blurred vision

.
Table 2: Prevention Strategies for Some Potential Work Hazards
.

HAZARD/EXPOSURE	EXAMPLES OF PREVENTION
1. Falls	- avoidance of job tasks requiring working on ladders, use of powered tools - worker education and training - proper use of personal protective equipment (gloves, goggles, work shoes)
2. Cutting tools	- avoidance of job tasks requiring use of powered and nonpowered tools - worker education and training on use of equipment - tool maintenance - personal protective equipment - first aid training
3. UV radiation, power machinery exhaust, heat	- warning labels clearly placed on containers of heat flammable liquids and equipment using such liquids - storage in safety containers - elimination of sources of ignition (cigarette lighters) - use of sun block to exposed skin areas, wearing a hat, shirt with sleeves - worker education and training - avoidance of machinery exhaust: proper ventilation - heat: proper hydration, rest
4. Pesticides, poison oak, ivy, sumac	- gloves, long sleeve shirt - pesticide exposure: avoid mixing, applying and loading pesticides - wash hands/exposed areas with soap and water after and before eating - launder contaminated clothing separately - remove clothing immediately if contaminated - worker education and training - review MSDSs
5. Noise from power equipment	- repair/replacement of excessively noisy equipment - hearing protection: earplugs, canal caps - worker education and training (OSHA hearing conservation standard) NOTE: there is no noise standard for agricultural workers
6. Ergonomic hazards	- less frequent lifting, lighter loads, assistance with lifting - maintenance of tools and equipment - choice of well designed tools (to minimize biomechanical disadvantage) - gloves to provide increased grip and to reduce vibration - task rotation, increased rest breaks

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HANDOUT

Summary of Federal Child Labor Laws: Age Restrictions

Federal minimum age standards for nonagricultural employment are described below.

Under Age 14

Most work is prohibited for children. However, youths may work at any age as actors or performers in motion pictures, theater, radio, and television productions. Children may also work for their parents if the parents are the sole owners of a business, in occupations other than manufacturing, mining, or hospital services children may also sell and deliver newspapers to customers and may do work not covered by the Fair Labor Standards Act (FLSA).

Ages 14 and 15

Youth may work in specified occupations during the following times:

Outside school hours
Between, 7:00 AM and 7:00 PM (9:00 PM between June I and Labor Day)
No more than 3 hours on a school day
No more than 18 hours in a school week
No more than 8 hours on a nonschool day
No more than 40 hours in a nonschool week

See sections on jobs Minors Can Do and jobs Minors Can't Do, below, for specific occupation restrictions.

Ages 16 and 17

At age 16, youth may be employed in any occupation other than a nonagricultural occupation declared hazardous by the Secretary of Labor (See section on Hazardous Occupations below).

Age 18 and over

Youth may work in any occupation for any number of hours.

Some provisions of the FLSA Child Labor Regulations are different for 14- and 15-year-olds who participate in approved school-supervised and school-administered Work Experience and Career Exploration Programs (WECEP). Enrollees in WECEP may be employed:

During school hours
For as many as 3 hours on a school day
For as many as 23 hours in a school week
In occupations otherwise prohibited for which a variation has been granted by the administrator of the Wage and Hour Division

Hazardous Occupations

The FLSA stipulates that for youth under the age of 18, the Secretary of Labor shall find and by order declare certain occupations hazardous or detrimental to their health and well-being. This minimum age applies even when the minor is employed by a parent or person standing in place of the parent.

The 17 hazardous occupations orders now in effect are as follows:

These hazardous occupations orders include prohibitions for minors under age 18 against operating certain other machines that may not be readily apparent from a quick reading of this list. Consult the nearest Office of the Wage and Hour Division if you have any questions about children using a particular machine.

HANDOUT

Application for Employment Certificate or Transferable Work Permit
PDE-4565 (10/91)
(1 page)

HANDOUT

NIOSH Update
Contact: Julie Tisdale (202) 260-9727
July 17, 1995

NIOSH Warns: Employment May be Hazardous for Adolescent Workers

Each year approximately 70 adolescents die from injuries at work, hundreds more are hospitalized, and tens of thousands require treatment in hospital emergency rooms.

The National Institute for Occupational Safety and Health (NIOSH)) recently released an Alert which details hazardous jobs for adolescent workers. The document reveals that motor vehicle deaths accounted for the greatest number of work-related deaths of 16- and 17-year-olds between 1980-1989. Motor vehicle deaths include delivery services, road construction work, and work at gas stations. Other leading causes of death include machine related incidents, electrocutions, assaults and violent acts, and falls. Related research indicates that many adolescent workplace deaths may be associated with activities prohibited by child labor laws.

"While the benefits of working are clear, we must recognize that thousands of adolescents are injured or killed in the workplace each year." said Dr. Linda Rosenstock, NIOSH Director, "Work should be a fulfilling and educational life experience for young people, not a life threatening one."

NIOSH estimates that nearly 64,000 adolescents required treatment in hospital emergency rooms for work related injuries in 1992. Burns associated with food service and sprains and strains due to overexertion are among the most serious. Sixty-eight percent of those injured experienced limitations in their normal activities for at least one day and 25% experienced limitations for more than a week. More than half of those injured reported that they had not received any safety and health training.

In addition to injuries, hazardous materials and working conditions are also a concern for adolescents. They may be exposed to pesticides in farm work and lawn care, benzene at gasoline stations, asbestos and silica in construction and maintenance work, and high levels of noise in manufacturing, construction, and agriculture. These exposures may result in immediate illness or may not be detected for months or years later.

The United States has more of its children in the workforce than any other developed country. We must ensure that our young people reap the benefits of employment without becoming victim to the hazards which all too often accompany work.

NIOSH requests assistance in protecting the safety of this country's working adolescent population. The following page contains information on how we can all do our part to protect the workforce of the future.

US DEPARTMENT OF HEALTH & HUMAN SERVICES
Public Health Service
Centers for Disease Control and Prevention
National Institute for Occupational Safety and Health

Developed by: Grace K. Paranzino, MS, RN; Harriet Rubenstein, MPH, JD; Eddy A. Bresnitz, MD, MS; Wayne Vaught, PHD

Supported by:
THE NATIONAL INSTITUTE OF ENVIRONMENTAL HEALTH SCIENCES ENVIRONMENTAL/OCCUPATIONAL MEDICINE ACADEMIC AWARD, #ES-00293
MCP Hahnemann University, 1997

This document was last modified on 06/14/2000 03:07:53 PM

This resource was acquired by CEEM (Consortium for Environmental Education in Medicine), a program of Second Nature, under the auspices of a NIEHS grant to gather and disseminate environmental health educational resources over the internet in order to help medical and allied health sciences faculty identify, locate and use resources for incorporating environment and health perspectives into their curricula. CEEM has authorized the use of these materials on this website for archival purposes. Please note that the copyright for this material is retained by the instructor and/or contributing institution.