1. Insulin treated diabetes mellitus and safety critical work
Insulin treated diabetes mellitus and safety critical work? Other than pilots…
Dr Tim Sprott
Aviation & Occupational Health
ANZSOM & AMSNZ Conference
Auckland 5 September 2015

2. Over riding principles…
Safety fitness for work vs functional fitness for work Medical standards must be relevant to safety critical work Safety fitness for work decisions by qualified competent health professionals Disclosure of relevant health information only

3. Over riding principles…
Inter-relationships with other health practitioners Privacy and confidentiality Anti discrimination / Human Rights legislation Reasonable adjustments and accommodations by employers

4. What is safety critical worker vs work?
Safety Critical Worker means a worker whose action or inaction, due to ill-health, may lead directly to a serious incident affecting the public or the rail network (Kiwi Rail)
Safety critical work
ICAO – “activities where uncorrected errors have an immediate and negative effect” on safety.
‘Safety critical work’ involves any activity, process or work related factor that can put the worker, other workers, the general public, the environment or property at risk of significant harm if it is not carried out correctly. This can be used to identify ‘safety critical workers’ and classify them based on individual assessment of fitness for work.

5. How safe?
What are acceptable maximum levels of risk of incapacitation? Professional pilots/ air traffic controllers 1-2% pa Professional drivers 2 % pa Aircraft engineers 2-5 % pa ? Airport ramp workers 2-5% pa ? Private vehicle drivers % pa

7. Air NZ Guidelines… Ethical obligations Effects of Health on Work
Meeting operational safety requirements, maintaining employment and not compromising the employee’s diabetes management
Effects of Health on Work
Effects of Work on Health
Regulations
Impact of co-existing medical conditions

8. Air NZ Guidelines Incapacitation Sudden – hypoglycaemia
Subtle – hypoglycaemia and hyperglycaemia

9. Air New Guidelines
Employee physically and mentally fit for their role Regular (minimum annual) review with a specialist or GP Diabetes under stable control Employees able to do SMBG and well motivated No disabling episodes of hypoglycaemia Hypoglycaemia awareness and management Absence of clinical evidence of microvascular complications that could cause functional incapacity Medic alert or similar Annual review with Aviation and Occupational Health services

10. Air NZ Guidelines Exclusion criteria In the last 12 months-
One or more episodes of hospitalisation due to hypoglycaemia
Hypoglycaemia resulting in a seizure , loss of consciousness, impaired cognition, or external intervention
One or more episodes of hypoglycaemia unawareness
Poor stability of control in the previous 3 months

11. Air NZ Guidelines Background health information
Copies of all diabetes medical records as well as accident information (work & driving accidents)
Completed medical report GP or specialist
Two HBA1cs at least 90 days apart
Details of diabetes management and insulin dosages/type
Assessment of CVS risk and presence of microvascular complications
Verification of employee education and understanding of diabetes, control and hypoglycaemia awareness/ management
Verification that an employee has the ability and willingness to self monitor BGs

13. Air NZ Guidelines Decision making criteria
Glycaemia control - HBA1c 48 – 70 mmol/mol
- SMBGs < 5% below 4mmol/l
80% between 5-15 mmol/l
Other factors – excessive frequency hypoglycaemia/ hyperglycaemia
- documented hypoglycaemia unawareness
- poor management and compliance

14. Air NZ Guidelines Operational requirements
Encourage employees to tell peers or line managers
Employee must carry during work
glucometer (and access to back up one for cabin crew)
adequate supplies of BM sticks
Rapidly absorbable glucose
Glucose testing minutes before work
Monitoring during work
Maintain glucose concentrations in the 5-15 mmol/l range
Cease working and take action if outside this range before returning to work
Emergency situations

15. Other technologies

16. What are the challenges in the airline flying environment?
Public and flight safety Acceptable rate of multicrew medical incapacitation of 1 x 10 -6/hrs Variable flight durations Critical phases of flight Subject to disrupted sleep and time zone changes In a variety of weather conditions Subject to changes in atmospheric pressure, noise, vibration and acceleration Reliant on support services including provision of food With little or no medical/health support With the potential for an emergency situations/mass casualty/survival situation to occur with little or no warning