Environmental investigations are complex and require thorough analysis. Many non-environmental illnesses can mirror symptoms typically associated with environmental conditions. Having a medical doctor familiar with environmental and occupational medicine is critical to the investigation team. Additionally, understanding risk communication and proper management of the message with focus on the psychology of the individual, the community and stakeholders is absolutely essential to the resolution of an Indoor Environmental Quality (IEQ) crisis. If people believe that there are toxins, infectious agents, or poisons within the building environment, then all will feel that they are affected, even if they do not come forward. A good IEQ investigation will thoroughly flush out the issues during the investigative process and create a risk communication plan which will enable a successful resolution. The following examples highlight the complexity of IEQ management.
"Nurse Epidemiologist Taken To Hospital For 'Bad Air'"
NE is a Nurse Epidemiologist with a history of asthma and diabetes who missed a significant number of workdays, complaining of a reaction to "bad air" at the workplace. Her requested accommodations, including a rotating fan to circulate the air, were honored. She returned to work and reportedly became hypoglycemic and "lost her airway" from a severe asthma attack. A co-worker had to administer an inhaler to her before she regained consciousness. The union began picketing the office complex. Four television stations were present to report the union action. A work excuse from her University Environmental Medicine physician attributed her symptoms to aggravation from the workplace. Suddenly, 45 other building occupants came forward with various non-specific symptoms.
An IEQ team was assembled. As the physician resource, I pointed out that despite her doctor's opinion, her symptoms did not seem medically appropriate. One does not recover from asthma severe enough to "lose airway" or consciousness, just by having a bystander squirt an inhaler into the patient's throat. If it were so easily resolved, as a nurse, she could have easily administered the inhaler herself, preventing the deterioration. Additionally, if one's medical condition were truly worsening, hyperglycemia (not hypoglycemia) is the rule.
Management then privately stepped forward with information concerning her work performance. She had missed a deadline eight weeks previously for a $6 million federal grant and was about to be terminated. She also was not getting along with her supervisor or co-workers. Her resume showed that she had been employed by nine different employers over the last eleven years. The picketing union was the smallest of six unions representing over 2,000 employees in the building.
Believing that the small union might turn this into a recruitment drive, the strategy was to form a building committee (BC) composed of employee representatives from the various departments and management/facility leaders. A comprehensive risk communication program was planned. Monthly BC meetings were held to educate the BC members and to respond to their constituents' IEQ concerns. By the fourth month, the IEQ complaints were mainly related to housekeeping issues.
During her independent evaluation, NE finally admitted to taking an un-prescribed, extra dose of insulin on the day of the incident for unclear reasons. Neither she nor her doctor (after review of all facts) was able to offer any legitimate medical explanation for her behavior or her protracted absence. She was referred to EAP and placed on probation. She failed to conform to the conditions of continued employment and never returned to the workplace. Over the past three years, no further media attention or employee complaints regarding this building have occurred.
"Eighteen Months Investigation Reveals Horse Behind Student's Symptoms"
We were called to review year-long complaints of nonspecific and upper respiratory tract symptoms including runny nose, watery eyes, sneezing, in a small cluster of elementary school students. A thorough investigation had been performed which revealed no evidence of mold, dust, dirt, pollen amplification. Other indoor environmental quality surveys, e.g., pest control issues, were also not revealing. Many risk communication meetings took place with parents and teachers. Despite being moved to another classroom as the children graduated from the initial grade level, symptoms continued.
Communication and information flow with primary care providers and allergists were coordinated. Through further investigation, it was later found that one child owned a horse which she combed routinely in the morning. She did not clean up or change her clothes after grooming her horse; therefore, she was exposing some of her classmates who were sensitized to horse dander.
In summary, these cases illustrate environmental investigations are complex and often require lengthy, time-consuming detective work, both clinically and environmentally, for resolution. Many environmental and non-environmental illnesses share symptom complexes and/or manifestations. Many of the conditions may be exacerbated by activities in general, or by activities at work. Therefore, comprehensive health and environmental evaluations along with an aggressive communication strategy are paramount to successful resolutions. In environmental health, it is not unusual for patients to be misdiagnosed: many clinicians in today's managed healthcare settings do not have the time for complex workups. Other clinicians, seeing themselves purely as patient advocates, are convinced by subjective history without performing objective testing. Other issues to consider when investigating IEQ situations include workplace agendas, issues with psychological overlay, subconscious manifestations of substance or physical abuse, etc. Thus, a comprehensive, multi-disciplinary, approach is often required to bring successful resolution to the often complex environmental investigations.
Hung K. Cheung, MD, MPH, FACOEM, has more than 10 years experience in environmental and occupational medicine. He worked on the Governor's IAQ Task Force. Please contact the author at firstname.lastname@example.org or (301) 963-7043 for further information regarding environmental health matters.