Sudden Cardiac Death in the Oil and Gas Industry: Is it Preventable? Fred Kohanna, MD, MBA, FACOEM

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1 Sudden Cardiac Death in the Oil and Gas Industry: Is it Preventable? Fred Kohanna, MD, MBA, FACOEM

2 SUDDEN CARDIAC DEATH IN THE OIL AND GAS INDUSTRY: IS IT PREVENTABLE? OSHA Oil & Gas Conference Houston, TX December 4, 2018 Presented by Fred Kohanna, MD, MBA, FACOEM Vice President of Occupational Health & Chief Medical Officer

3 WHAT WE ARE GOING TO TALK ABOUT Definition and incidence of sudden cardiac death (SCD) Risk factors for sudden cardiac death Causes of sudden cardiac death SCD in the Oil & Gas industry Lessons learned in firefighting and law enforcement research SCD in other work environments The cost of SCD (productivity, financial, emotional) Support for co workers after a SCD in the workplace Prevention of SCD in the workplace Conclusions

4 DEFINITION OF SUDDEN CARDIAC DEATH (SCD) Sudden cardiac death is usually defined as an unexpected natural death due to a cardiac cause that occurs within one hour of the onset of symptoms.

5 INCIDENCE OF SUDDEN CARDIAC DEATH (SCD) It is estimated that 7 million lives are lost worldwide each year from SCD In the U.S., SCD is responsible for 300,000 to 400,000 deaths annually. Of these deaths, 13 15% die in the workplace

6 CAUSES OF SUDDEN CARDIAC DEATH (SCD) Coronary artery disease (CAD) Up to 80% of victims of SCD have CAD Left ventricular hypertrophy (LVH) increased wall thickness and mass of the heart; Cardiomegaly increased heart size and mass Cardiomyopathy abnormal heart muscle Hypertrophic Dilated Valvular heart disease aortic, mitral, pulmonic, tricuspid Congenital anomalies of the heart Arrhythmias disturbance of the normal electrical conduction and rhythm of the heart

7 RISK FACTORS OF SUDDEN CARDIAC DEATH Family history of premature coronary artery disease or cardiomyopathy or rhythm disturbances Smoking Dyslipidemia (elevated cholesterol and/or triglycerides) Hypertension Diabetes Obesity Obstructive sleep apnea Sedentary lifestyle Age Gender

8 DEVELOPMENT OF CORONARY ARTERY DISEASE (CAD) The coronary arteries supply blood to the heart muscle Blockages in the coronary arteries can occur as a result of atherosclerosis ( hardening of the arteries ) As these blockages (or plaques) get worse, they can restrict blood flow to the heart muscle Atherosclerotic plaques in the wall of the coronary arteries can become completely blocked, or can fracture, resulting in formation of a blood clot (thrombus) that blocks the coronary artery. The area of heart muscle supplied by that coronary artery will then undergo cell death (infarction).

9 DEVELOPMENT OF CORONARY ARTERY DISEASE (CAD) Normal Fatty streak Lipid-rich plaque Foam cells Fibrous cap Thrombus Lipid core

10 CORONARY ARTERY DISEASE (CAD) MYOCARDIAL INFARCTION (HEART ATTACK)

11 LEFT VENTRICULAR HYPERTROPHY (LVH)

12 ETIOLOGY OF LEFT VENTRICULAR HYPERTROPHY (LVH) AND CARDIOMEGALY* High blood pressure Coronary artery disease Cardiomyopathy Obesity Valvular heart disease *LVH and Cardiomegaly raise the risk of fatal arrhythmias

13 THE U.S. OBESITY EPIDEMIC

DILATED CARDIOMYOPATHY Dilated Cardiomyopathy is caused by: Viral infection Autoimmune diseases Genetic Environmental (alcohol) Coronary artery disease (CAD) Extensive fibrosis of the

14 DILATED CARDIOMYOPATHY Dilated Cardiomyopathy is caused by: Viral infection Autoimmune diseases Genetic Environmental (alcohol) Coronary artery disease (CAD) Extensive fibrosis of the subendocardium of the heart muscle results in arrhythmias 10% of cases of sudden cardiac death (SCD) are attributable to Dilated Cardiomyopathy Prognosis is poor with a one year mortality rate of 10 50%

HYPERTROPHIC CARDIOMYOPATHY A genetic disorder affecting one of more than 45 genes that encode for the heart muscle Sudden cardiac death (SCD) can occur at rest,

15 HYPERTROPHIC CARDIOMYOPATHY A genetic disorder affecting one of more than 45 genes that encode for the heart muscle Sudden cardiac death (SCD) can occur at rest, during mild exercise, or during strenuous exertion Many people with this condition do not know they have it and have no symptoms Cause of death is usually an arrhythmia

16 VALVULAR HEART DISEASE ONE EXAMPLE: AORTIC STENOSIS

17 ARRHYTHMIAS ELECTRICAL CONDUCTION SYSTEM

18 ELECTROCARDIOGRAM (EKG): NORMAL AND ABNORMAL ELECTRICAL CONDUCTION

SUDDEN CARDIAC DEATH (SCD) IN VARIOUS OCCUPATIONS (U.S.) Percentage of occupational deaths caused by SCD: Firefighters 45% Law enforcement 22% Construction 11.

19 SUDDEN CARDIAC DEATH (SCD) IN VARIOUS OCCUPATIONS (U.S.) Percentage of occupational deaths caused by SCD: Firefighters 45% Law enforcement 22% Construction 11.5% Emergency Medical Services 11% Overall 15% (all industries including Oil & Gas)

20 FATALITIES & SUDDEN CARDIAC DEATH (SCD) IN THE U.S. OIL & GAS INDUSTRY 2003 to 2014

SUDDEN CARDIAC DEATHS (SCD) IN THE U.S. OIL & GAS INDUSTRY 2014 Very limited data available: CDC/NIOSH Fatalities in Oil & Gas Extraction (FOG) database 2014:

21 SUDDEN CARDIAC DEATHS (SCD) IN THE U.S. OIL & GAS INDUSTRY 2014 Very limited data available: CDC/NIOSH Fatalities in Oil & Gas Extraction (FOG) database 2014: 101 work related fatalities (3 were cardiac) 11 deaths at work not definitively work related (10 were cardiac) 13 out of 112 FOG events in 2014 were cardiac (12%)

22 SUDDEN CARDIAC DEATHS (SCD) IN THE U.K. NORTH SEA OIL & GAS INDUSTRY 2011 & 2012 There were 9 deaths in the U.K. North Sea sector of which 8 were attributable to sudden cardiac death 3 of 8 were in workers age 40 to 50 5 of 8 were in workers over age 50 Cardiovascular illnesses were a major cause for medical evacuations from North Sea platforms

SUDDEN CARDIAC DEATH (SCD) IN THE FIRE SERVICE Very limited research is available for SCD in the workplace The best studied occupation is firefighting Dr.

23 SUDDEN CARDIAC DEATH (SCD) IN THE FIRE SERVICE Very limited research is available for SCD in the workplace The best studied occupation is firefighting Dr. Stephanos Kales and his colleagues at the Harvard School of Public Health have done pioneering research in this field Information developed for SCD in firefighters has broad applicability to other jobs that involve intense physical activity

24 SUDDEN CARDIAC DEATH (SCD) IN THE FIRE SERVICE SCD risk is especially high among firefighters Why is this? Initial alarm triggers fight of flight adrenaline response with increase in blood pressure and heart rate Structural firefighting involves very strenuous activity including climbing, search and rescue, cutting and chopping, and handling hose lines Work is performed in heavy turnout gear and SCBA Heat stress and dehydration are common Blood becomes thicker and more likely to clot in coronary arteries Exposure to carbon monoxide, hydrogen cyanide, hydrogen sulfide, particulates Even though fire suppression is less than 5% of a firefighters work activities, it accounts for 32% of work related SCD. Kales, et al, N Engl J Med 356;12 March 22, 2007

25 SUDDEN CARDIAC DEATH (SCD) IN THE FIRE SERVICE March 17, 2017 WATERTOWN, Mass. (AP) A firefighter who collapsed and died after responding to a house fire Friday morning was a 21 year veteran of the department and a married father of five children, colleagues said.

26 RISK FACTORS FOR SCD IN FIREFIGHTERS Smoking and/or environmental tobacco smoke Obesity (BMI >30) Hypertension Age >45 High Cholesterol Diabetes Prior diagnosis of coronary artery disease Cardiomegaly or left ventricular hypertrophy Lack of exercise Shift work and overtime

SUDDEN CARDIAC DEATH (SCD) IN LAW ENFORCEMMENT A 35 year old Sergeant with the Hope Mills, NC, Police Department suffered a fatal heart attack while he and his K9 partner

27 SUDDEN CARDIAC DEATH (SCD) IN LAW ENFORCEMMENT A 35 year old Sergeant with the Hope Mills, NC, Police Department suffered a fatal heart attack while he and his K9 partner searched a wooded area for a person who had fled from officers on foot. He had served with the Hope Mills Police Department for 9 years. He is survived by his wife and two children.

28 SUDDEN CARDIAC DEATH (SCD) IN LAW ENFORCEMENT Varvarigou, et al, BMJ 2014;349:g6534 Studied 441 sudden cardiac deaths in police officers The overall fatality rate among law enforcement officers is per 100,000 full time workers Most fatalities are traumatic but 7% are due to SCD The risk of SCD when compared to routine police duties was: times higher during restraints/altercations times higher during pursuits times higher during physical training 6 9 times higher during medical/rescue operations Conclusion: The most likely explanation for these findings is a sudden increase in cardiovascular demand because of a combination of physical exertion and psychological stress, consistent with fight or flight physiology

SUDDEN CARDIAC DEATH (SCD) ON A SEA GOING SHIP Wojcik Stasiak, et al, Int Marit Health, 2011; 62, 2: 110 115 This study analyzed 30 SCD cases on Polish sea going ships between 1998 and 2009 Genetic

29 SUDDEN CARDIAC DEATH (SCD) ON A SEA GOING SHIP Wojcik Stasiak, et al, Int Marit Health, 2011; 62, 2: This study analyzed 30 SCD cases on Polish sea going ships between 1998 and 2009 Genetic and environmental factors affecting SCD included: Diabetes Obesity Elevated cholesterol Hypertension Family history of premature heart disease Pre existing coronary artery disease Work related stress (high job demand/low control); emergency situations; work conflicts Strenuous static and dynamic physical exertion* Heat stress* * Usually preceded SCD

30 ARE OTHER OCCUPATIONS AT RISK FOR SCD? Any worker in any industry that involves strenuous physical activity is at risk for SCD. Risks are increased with sudden maximal exertion, stressful situations, heat, humidity, PPE, and respirator use. Some examples of job in this category are: Mining Field services (e.g. hazardous waste) Commercial driving (loading and unloading) Construction Landscaping Manufacturing And many, many others

31 ARE WHITE COLLAR WORKERS AT RISK FOR SCD? Zhang, et al, published a research study in 2015 in the BMJ entitled Occupation and risk of sudden death in a United States community: a case control analysis. The study demonstrated that A white collar occupation was associated with increased risk of SCD, when compared to blue collar occupations. Since differences in conventional risk factors did not explain this elevated risk, work related behavioural and psychosocial stressors warrant a closer evaluation In Japan, the phenomenon of Karoshi has been recognized since These are well documented cases of white collar workers who had SCD after literally working themselves to death by excessive work hours, high work related stress levels, lack of sleep, and business dinners involving excessive alcohol consumption.

32 THE COST OF SUDDEN CARDIAC DEATH (SCD) Replacement of a worker who has sustained sudden cardiac death can cost 175% of the deceased worker s salary Potential increase in Workers Compensation rates for 3 years Decreased productivity due to: Emotional distress (e.g. shock; depression; anxiety; guilt; inability to concentrate; anger) Disruption of normal workflow due to the absence of the deceased employee Negative attitude and/or resentment toward the employer Miscommunication/rumors/gossip Negative impact on co workers health (e.g. headaches, musculoskeletal complaints)

SUPPORT FOR CO WORKERS AFTER A SCD IN THE WORKPLACE Consider allowing co workers (if possible) to go home after a sudden cardiac death in the workplace Keep employees informed about the circumstances

33 SUPPORT FOR CO WORKERS AFTER A SCD IN THE WORKPLACE Consider allowing co workers (if possible) to go home after a sudden cardiac death in the workplace Keep employees informed about the circumstances of the SCD even if full information is not yet available If employees are not informed, they may fill the information void with rumors, and may resent the company for keeping them in the dark Consider if it would help to make temporary changes in the work schedule or break times Consider allowing time for co workers to attend the funeral Employee assistance programs can be invaluable for providing individual counseling, or group critical incident debriefings

PREVENTION OF SCD IN THE WORKPLACE Pre placement physical exams Periodic physical exams Establish criteria for cardiac stress tests for high risk job categories Fitness for duty and return to work

34 PREVENTION OF SCD IN THE WORKPLACE Pre placement physical exams Periodic physical exams Establish criteria for cardiac stress tests for high risk job categories Fitness for duty and return to work medical clearances Fitness/Wellness programs (on site or off site) Automatic external defibrillator programs (AED s) Know your numbers programs (BP; Cholesterol; BMI; fasting blood sugar or HgbA1c) Workplace smoking and tobacco product ban Restrict employees with known coronary artery disease or other significant cardiac problems from certain job classifications (e.g. fire brigade)

35 CONCLUSIONS 1. Sudden cardiac death is a common problem in the workplace including the Oil & Gas industry 2. Most of the research in this area has been done in firefighters and this information can be extrapolated to other strenuous jobs 3. Risk factors for SCD are well known and can be mitigated 4. Workers in high risk jobs can be screened for cardiac disease 5. Wellness/Fitness programs are essential for reducing the risk of SCD 6. If an SCD should occur, the well being of co workers must be considered and addressed The bottom line: SCD in the workplace IS preventable!

36 DISCUSSION & QUESTIONS?

37 Up Next...Breakout Sessions 11:30am-12:15pm 1. RAGAGEP: OSHA Wants Me to Do What?? Mike Marshall, Room 335-A 2. A Multi-State Initiative to Examine Workers Compensation Claims For Oil and Gas Extraction Workers Kyla Retzer & Dr. Kyle Moller, Room 335-B 3. Investigations the H&P Way (The SIF Model) Wade Deer, Room 335-C 4. Driving Transformation: How to Actively CARE Mark Crelia, Room 336-AB 5. Heater Burner Automation Reduces Operator Injury Risk Ron Truelove, Room 337-AB 6. Overcoming Unconscious Incompetence: The Hidden Problem in Safety Training Nick Howe, Room 339-AB 7. Increasing Employee Engagement & Empowerment Utilization and Recurrent Risk Assessment Approach Robert Sheninger, Room 340-AB 8. The Impact of Safety Performance Metrics on Contractor Behavior Phillip Crawley, Room 343-AB 9. Release for Unrestricted Use and Transfers Involving NORM Contamination Geri Blanchard, Room 346-AB

38 Up Next Tuesday Lunch - Grand Ballroom 12:15pm 1:45pm - Speaker: Kola Fagbayi, Vice President of HSE & Technology BP - Keynote Speaker: Johnny Joey Jones, Combat-wounded Staff Sergeant (Ret.), Motivational Speaker CEUs - Receive 1.3 CEUs (13 hours) for attending conference - Submit form at Customer Service Desk at the conclusion of the conference Download the App Visit and download the 2018 OSHA Oil & Gas Safety and Health Conference Mobile App

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