Dr. Al Baltracitis, DO, MPH. He's residency trained and board certified in family practice and occupational medicine. He's practicing exclusively in occupational medicine since 1992. Medical director for occupational medical department and associated health and wellness of Ascension, Wisconsin, Wheaton, Franciscan healthcare and occupational medical consultant for Johnson Controls Incorporated. Another outstanding presentation. Thank you so much, sir. Thank you. Good morning, everyone. My name is Al Baltracitis. And I have no disclosures. First, the bad news. Boston, Massachusetts, in a report that is both shocking yet not shocking at all, a Harvard University report states that healthcare professionals spend 55% of their workday in front of an electronic health record, while the other 45% of their time is spent rigorously cursing out their electronic health record. Now, I don't know what type of health record you have. I have EPIC. They all suck. I'm sorry. You know, what's sad about the electronic health record, medical record, is that it is gradually leading to the extinction of the face-to-face patient encounter. It's gradually being replaced by the face-to-screen encounter. I think this is a little bit more true in younger physicians. I went to see a young doctor. He's a fellow. He had his face in the screen the whole time. It's very, very, very unfortunate. And some of this is, for example, EPIC, my organization, just changed the security lockout to 10 minutes. So, you're out. You almost have to have your face in the screen actively. Otherwise, it gets logged out, okay? And then what happens? It gets logged out. You know, after 100 more times of logging back in, not only do you get frustrated, you get carpal tunnel too. Does this have anything to do with the reproductive issues? No. I just like to complain about EPIC. That's all. So, our overall outline and goals, we're going to review fertility in females and males. We're going to review pregnancy and spontaneous abortions. We're going to talk about teratogens. Teratogens are substances that may produce physical or functional defects in the human embryo or fetus after the pregnant woman is exposed, you know. Amen. You have a comment while you're getting back up there. If you can't see the comments, Dr. Cochran, I'd say I don't believe that was a complaint. That was pointing out a simple truth. Amen. Thank you. Thank you. We're going to talk about teratogens and some of the common concerns. You know, awareness of pregnancy is an issue because teratogens affect the embryo early in the pregnancy, and some women don't know they're pregnant right away. We're going to discuss a couple legal cases, Johnson Controls and UPS. We'll also review employer responsibilities and discuss work recommendations during pregnancy. Now, first off, there's background assumptions. In a perfect world, in a perfect world, everyone, men and women, should be able to have as many children as they want, when they want, in a perfect world. In a perfect world, every child should be perfect, and workplace hazards should not interfere with number one or number two. What is a reproductive hazard? These are substances or agents that affect the reproductive health of women or men or the ability of couples to have healthy children. What are the populations of concern? There are three groups of employees with concerns that women of childbearing age, there's men and the women who are pregnant, and determining the exact cause of concern is very, very important, okay? So, we'll start with fertility issues in men and women. There's a question, as an occupational doctor, just as a physician, period, you have a very important question. The patient comes up and says, Doctor, I work with substance X, and is that substance, is my work with substance X going to interfere with my ability to get pregnant or my partner's ability to get pregnant? So, your response has to incorporate several different issues, okay? You have to have some knowledge of the scientific literature regarding substance X. You have to know, well, how does that substance interfere with getting pregnant? Does it affect only men? Does it affect only women? Does it affect both of them? What is the level that will affect the ability to get pregnant? You have to kind of quantify the work exposure. It's, you know, when someone comes up to you and they say, well, I work with lead. Well, what does that mean? Do they work in the pasting department where their coverage had to toe with lead? Or do they work in formation where there's lead, but it's inside the battery, so there's not a whole lot of exposure? Or do they work with lead because they're an administrative assistant on the fifth floor? So, you have to be able to quantify the work exposure, and you have to be sensitive to the fears and concerns of the patient, you know, you don't want to panic them, but then, you know, if there's really no significant exposure, there's no significant risk, you have to be able to explain to them in terms, in ways that they will understand, okay? And as we all lucidly recall from medical school, meiosis is the formation of sex cells, and in the female, oogenesis is a formation of the egg cell. Only one egg is formed, the other three cells are polar bodies, they just disappear. The egg cells are formed to a point in the first division before the female is born, the eggs mature after puberty, one or more with each menstrual cycle. In the male, spermatogenesis is the formation of the sperm. Four sperm cells are formed from one parent cell. Sperm cells do not start to form until puberty in the males, and then they continue on and on. Now, in the male, spermatogenesis is an ongoing process, as I said. It's a 70- to 80-day period of high-rate cell division in adult men. It's very susceptible to adverse influences. The normal values are such that sperm production is between 20 and 350 million per day, and the human ejaculate is about 50 to 150 million sperm per milliliter. And spermatogenesis is dependent on the hormonal milieu, temperature, DNA repair mechanisms. And just the spermatogenesis is not the only important part of male reproduction. You have to worry about sexual performance, which is also dependent on the hormonal milieu and vascular function. Now, fertility criteria is defined as greater than 20 million sperm per milliliter of semen. You have to have greater than 40% motile sperm. You have to have greater than 70% normal morphology. About 20% to 30% of infertile couples' workups determine the cost to be male, and then 10% to 15% are both. About 1% of all men have no sperms. Okay, now let's get into the…let's get into the things that can affect male fertility. Dibromochloropropane, DBCP. If you want an easy way to remember it, just think of Dow birth control pill, okay? I'll explain it in a second. Now, dibromochloropropane is a nematocyte. They used to use it in banana production. Nematodes are parasites, little worms. They would just decimate the banana crops, okay? Unfortunately, DBCP induced testicular dysfunction. It caused oligospermia and azospermia, caused drops in plasma FSH and LH. It caused decreased rates of male offspring. There was some recovery after the exposure was ended. Sperm counts recovered in about a third of the exposed men. Recovery took 36 to 45 months. The other two-thirds did not recover. So, basically, what happened, the Dow Food Company was using this DBCP in the banana workers. They noticed difficulty conceiving children. And what happened in 1977, the Dow Chemical Company stopped production, and they reclaimed the product. They reclaimed the product from around the world. It all came back to Dow. Well, Dow Food Company said, wait a second, that's going to screw up our banana crops. So, they threatened to sue Dow if it stopped shipment to the banana plantations in Nicaragua and Latin America. So, what did Dow do? They took all that reclaimed product. They shipped it to Latin America. Well, no, the workers got upset. They sued. Crimes against humanity, genocide, stuff like that. And you'd think that this would be a slam dunk. They would get millions and millions of dollars. And some workers did get some money. But the Nicaraguan legal system, there was some corruption, some ineptitude, some fraud, extortion, statutes of limitations weren't followed. And they really didn't get a whole heck of a lot, unfortunately. In 1979, the EPA banned the use of DBCP except for use on pineapples in Hawaii until 1985. So, I don't know what the fertility of the male pineapple workers in Hawaii was at that time, but I was just surprised that they kept using it until 1985. Temperature. Sperm production is best a few degrees below normal body temperature. Work in a hot environment like a bakery or foundry may interfere with sperm production. Sitting still for long periods can also overheat the testicles. What about office work, driving long distances, sitting with a laptop on your lap for long periods? You know, there is no proof. I mean, those are all good thoughts, but there's no proof of a link between sitting long periods and laptops and fertility, okay? Now, what about men who work in pharmaceutical manufacturing? They're producing birth control pills. There's significant exposure to the agents contained therein. The effects of these medications interfere with usual hormonal processes. Prevention is the key. All these workers, all exposed workers use PAPRs. A PAPR is a powered air purifying respirator. You do biological monitoring, baseline and periodic. You have to time the testing to maximize likelihood of a result. So, you don't want to do biological monitoring on a Monday when they've been away from work all week and you want to do it on a Friday when they've been at work the whole week, okay? Now, you know, what is a PAPR? You know, why is that important? Well, I'm going to—this is a little bit off topic, but I think it's important for occupational medicine to know a little bit about the assigned protection factor. The assigned protection factor is a workplace level of respiratory protection that a respirator or class of respirators is expected to provide. So, easy way to remember the assigned protection factor is the concentration of harmful substance on the outside of the mask divided by the concentration under the mask, okay? You know, for example, you have your half mask, the N95 has an assigned protection factor of 10. So, that means if you have, let's say, 50 micrograms per cubic meter of lead on the outside, if you're using the mask correctly and it's fitted correctly, and the assigned protection factor is 10, so that means if there's 50 micrograms outside the mask, there's going to be 5 micrograms inside the mask, okay? Now, the PAPR has an assigned protection factor of 25, okay? So, that means if you're—so, that means the exposure of the substance on the outside of the PAPR is—if the concentration is 50 on the outside and the assigned protection factor is 25, that means inside the mask, it's down to 2, okay? What if you have a full-face respirator? The assigned protection factor is 50, so that means the concentration outside the mask, if the concentration outside the mask is 50, on the inside of the mask, it's 1, okay? So, the higher the assigned protection factor, the greater the protection, okay? And there's all kinds of other respirators here. I like the SCBA has an assigned protection factor of 10,000. Now, you know, we have a one-year-old grandson who came to visit over Christmas. He's great, but I haven't changed diapers in 30 years, and I—right now, that APF of 10,000 sounds pretty good. Okay, other known hazards, lead. Lead decreases sperm count and quality. Mercury, you get—you can have decreased and or abnormal sperm. You have hormonal dysfunction. M, dinitrobenzene, that's used in the production of TNT and explosives. You have decreased fertility. You see decreased fertility. Ethylene glycol, monomethyl ether in the polyester production and antifreeze disrupts Sertoli cells. So, there's a lot of things that can affect men. Let's talk about women now. Now, just some statistics. There's about 11% of all women have impaired fecundity. About 6% of women who are infertile—there's about 6% of women are defined as being infertile. That means they're unable to get pregnant after at least 12 consecutive months of unprotected sex. And a number of women age 15 to 44 who have ever used infertility services are 7.4 million. So, there's a lot of issues in the female population. Now, female reproduction, the entire component of ova are present at birth and the number decreases with age. Approximately 400 mature ova are released during ovulation in a lifetime. Release of specific factors from the hypothalamus and hormones from the pituitary reduce the development of the ovarian follicle. Now, the follicle expels the mature ovum at the peak of the estrogen and luteinizing hormone levels approximately 14 days after the beginning of menses. Fertilization and early development occur during the ensuing few days and are followed by implantation into the uterine wall. Disruption of the hormonal balance between the brain, pituitary, and ovaries may result in estrogen and progesterone imbalances, changes in menstrual cycle length, menstrual irregularity, and failure to ovulate. What are potential causative factors? Stress could be physical stress or emotional stress. Chemicals, carbon disulfide, xylene, metals, inorganic mercury, ionizing radiation, these all can affect the menstrual cycle. What are some of the issues associated with spontaneous abortion? Well, anesthetic gases are associated with spontaneous abortion, arsenic, carbon disulfide, ethylene glycol, ethers, inorganic mercury, lead as well, okay? Pregnancy outcomes. So, this is question number two. Doctor, I'm pregnant. If I work with substance X, will it hurt my baby? Well, once again, you have to look at the literature. What does the literature say about this substance, and does this substance affect the pregnancy? Will it hurt the baby? What part of the pregnancy will it affect, okay? Now, once again, what is the exposure? Is there high exposure, low exposure? What type of PPE is the person using? Does the person have a simple surgical dust mask, which is almost nothing, or does the person have an SCBA, which has an assigned protection factor of 10,000? And once again, you have to be sensitive to the fears and concerns of the patient, okay? What are some of the normal rates, okay? Well, remember, in a perfect world, everyone can get pregnant and everyone can have a perfect baby, but, you know, we don't live in a perfect world. 10 to 20% of pregnancies result in spontaneous abortion. 30 to 40% of spontaneous abortions have a chromosomal anomaly. 2 to 4% of fetuses are stillborn. 7% of births are low birth weight. 3% of newborns have birth defects or congenital anomalies. 24% of births are severe mental retardation. 3% of anomalies in live births will manifest during the postnatal period or later in the development. 67% of all congenital anomalies or malformations have no known cause. And when these types of things happen, there's guilt. The parents think, oh my, what happened? What did we do? It's very difficult to accept. There could be anger. They can assign blame. You know, there must be something at work. It must be, you know, something else happened. And, you know, and there's enough lawyers around saying that, I mean, I've heard lawyers say, you show me a bad baby, I'll show you malpractice or product liability or something like that. So we have to look at, well, what's the reality as far as drugs and environmental agents? Well, drugs and environmental agents are implicated in only approximately 3% of congenital anomalies or malformations. So someone has an unfortunate outcome in a pregnancy, you can't just automatically blame it on work. Only 3% of congenital anomalies or malformations are related to drugs or environmental issues. One to 2% are maternal metabolic imbalances, two to three are infection, three to 5% chromosomal aberrations, 20% known genetic transmissions, and 70% are unknown factors. We just don't know. We just don't know. Now, fetal development. The weeks three through eight are the embryonic stage, organogenesis. Weeks nine through 14 are organ growth. Adverse reproductive outcomes can occur at any of these points, but organogenesis is the most susceptible, and that most susceptible time is very early in a pregnancy where some women don't know if they're pregnant. They don't know that they're pregnant at that time. Teratogens. An agent or factor that results in birth defects or malformations in a developing embryo, but does not result in any significant toxic effects to the mother, okay? So in other words, the mother's fine. It's the baby that has a problem, okay? Very, very, very famous teratogen is thalidomide, okay? Thalidomide entered the German market in 1957. It was over-the-counter, and it was advertised as being completely safe. The manufacturer said they could not find a dose high enough to kill a rat. At one time, one out of every seven Americans in the late 50s was taking thalidomide as a sedative, okay? Well, they started doing off-label use, using it for morning sickness, okay? Well, some Australian MD said, wait a second, I'm noticing something here. I'm getting all these babies with short limbs and all kinds of other defects. Eventually, it was banned in this country in 1962. Some countries kept it going, though. I think in Spain, it was used through the 80s. Mexico, too. Mexico, too, okay. Yeah, I mean, I think there's still some use for it now. I think leprosy and multiple myeloma, there might be some use for thalidomide. And the thing about thalidomide, too, it depends when did you take it, okay? If you took it on day 20 of the pregnancy, you'd have central brain damage. Day 21, it could be eye damage. Day 22, ears and face. Day 24, arm deformities. Day 28, leg deformities. And there's really no damage if you took it after day 42. So that organogenesis in the early part of the pregnancy, depending when you're taking it, you could have all kinds of damage. The general principles, susceptibility varies with the development stage of the fetus at the time of exposure. That's the example I gave with thalidomide. Agents act with specific mechanisms on developing cells and tissues. The susceptibility may vary with the genotype of the conceptus, and timing and dose may impact outcomes. Very, very important. So teratogenic effects may be dose-related. A very high dose could be embryo-lethal, kill the fetus, kill the embryo. Moderate dose, it might not have death. It could be just an embryological defect. Low dose, it may produce no effect at all. Now, Paracelsus was a Swiss physician in the 16th century. He was a father of toxicology. This statement was attributed to him. What is there that is not a poison? It's the dose that makes the poison. Think of water. You can have a glass of water, it's not gonna bother you. Drink a gallon of water, you're gonna get sick. You fall in the middle of the pool and you can't swim, you're gonna drown, okay? So the dose, it's the dose. Suspected teratogens, neurologic dysfunction in children. You see that with lead, okay? Now, there's an interesting monograph, okay? It's called the National Toxicology Program Health Effects of Low-Level Lead. It's very, very interesting. The NTP concludes that there is sufficient evidence that blood lead levels less than five are associated with adverse neurologic effects in children. Okay, and there's a lot of things that lead can cause. Decreased academic achievement, IQ. Well, I shouldn't say cause, associated with, okay? NTP concluded that there's sufficient evidence that there's decreased academic achievement, decreased IQ and specific cognitive measures. There's increased incidence of attention-related behaviors and problem behaviors. There's limited evidence that there's delayed puberty and decreased kidney function in children. There's sufficient evidence of delayed puberty, reduced postnatal growth, decreased IQ, decreased hearing. Yeah, lead is not a good thing for little kids, okay? Childhood cancer is seen with ionizing radiation exposure, CNS defects and malformations, organic mercury exposure, ionizing radiation, vinyl chloride monomer. Other impacts on pregnancy. Low birth weight is seen with arsenic exposure, carbon monoxide, PCBs. Prematurity of lead, physical stress can result in prematurity. Let's talk about the male reproductive system development, okay? Sexual differentiation begins at about seven weeks after conception is completed by the fourth month of gestation. FSH acts on Sertoli cells and testes to release LH. LH stimulates the testicular lighting cells to produce testosterone. Although males and females have identical FSH and LH, it is the hormonal effects on sex-specific target cells that produce sexual differentiation. Birth defects. Two to 3% of births, there's some type of major birth defect. Most cases, the cause is unknown. The first three months of pregnancy, that's the most important. That's where they have the organogenesis. That's the greatest susceptibility of some type of damage to the embryo. Many women are unaware that they are pregnant during much of this critical period. And you think, well, how could that be? I had a medical assistant in my office. She, one Monday, she wasn't there. I said, well, what happened to her? Well, she had a baby on the weekend. What are you talking about? Had a baby. She had belly pain, belly cramp, went to the ED, popped out a kid. She swears, she swears, she swears that she did not know she was, she's a kind of large lady. She's a perfectly healthy baby girl, but she swore that she did not know she was pregnant. How do you go nine months and not know you're pregnant? But it, I guess it can happen. Let's talk about low birth weight and premature birth. 7% of US births are born prematurely or are underweight. And these babies are more likely to become ill and die during the first year of life. Potential associations, poor maternal nutrition, smoking, alcohol use during pregnancy. Developmental disorders, failure of the brain to develop normally. It can lead to developmental delays or learning disabilities later in life. 10% of the children in the US have some form of developmental disability. Let's talk about Minamata disease. This is on every OCMED board question or Toxicology board question I've ever seen, okay? Minamata, okay. The CHISO Corporation is a chemical factory in New York. It's in Japan and it dumped stuff into the Minamata River and Harbor from 1932 to 1968. And they were like the largest chemical plant in Japan. They would dump inorganic mercury, methylmercury, lead, vanadium, sallium, selenium. I mean, you name it, they dumped it, okay? And the pollution was so heavy that you can get two kilograms of inorganic mercury from every ton of sediment. They actually, it was actually economically viable to mine the sludge, okay? So they'd set up a subsidiary to reclaim and sell the mercury recovered from the sludge that they dumped into the Harbor, okay? So anyway, what happened to the inorganic mercury? It was bio-converted to methylmercury. It bio-accumulated in the food chain in nearby bays. Humans consumed the shellfish and the fish and so did local animals. And there was severe methylmercury poisoning, okay? These people would develop ataxia, numbness in the hands and feet, general muscle weakness, loss of peripheral vision, damage to hearing and speech. Extreme cases included insanity, paralysis, coma and death. Could be fatal within weeks of the symptom onset, okay? And the congenital form for maternal exposure, you had excess rates of cerebral palsy and other infantile neurologic disorders in the region. You saw that for decades. In 1961, medical professionals reexamined kids diagnosed with CP. The symptoms of the children closely mirrored those of adult myelomotic disease patients, but most of those mothers did not exhibit symptoms, okay? Many of the impacted kids were born after the initial outbreak and had never consumed contaminated fish. The medical establishment at that time had believed that the placenta would protect the fetus from toxins in the bloodstream. Unfortunately, the opposite was true with methylmercury. The placenta removed it from the mother's bloodstream, protecting the mother and concentrated the chemicals in the fetus. Very sad. Obviously, you figured there'd be lots of big lawsuits and everything else, but the company was so powerful and had such profound loyalty in the area that people were afraid to sue the company. They just wouldn't. They would be shunned. They would be ostracized. So they just kind of sucked it up. I mean, there were some lawsuits. There were some lawsuits, but by and large, not what you would expect. Childhood cancer. Ionizing radiation exposure increases the risk of cancer in children whose mothers were exposed during pregnancy. Preventive measures. You minimize use of x-ray on pregnant women. Use newer equipment that reduces the x-ray dose. Use of protected shields. Most women will not want to have any type of an x-ray if they're pregnant. Legal cases. These are fun. UAW versus Johnson Controls, 1991. Now, Johnson Controls has been around for 100 years. They used to have three divisions. The Controls Division, that means the thermostats and things that control environment inside buildings. And they had an Automotive Division. The Automotive Division made car seats and dashboards. And then they had the Power Solutions, which was the Battery Division. Now, they've spun off the Automotive Division. They spun off the Battery Division. Battery Division is now owned by Clarios. It's a separate company. But at that time, in 1991, it was a part of Johnson Controls. I've been a medical consultant slash director for Johnson Controls since 1995. I had nothing to do with the Supreme Court decision. Now, so they were manufactured, Battery Division was manufacturing batteries, okay? And lead-exposed jobs in battery assembly were the highest paid in the factory. Now, due to concerns that children of workers who are outside the Exclusive Remedy of Workers' Comp would sue the company, they decided, the company decided to exclude pregnant and potentially fertile women from the most lead-exposed jobs. And this was with the support of their medical director at the time. And this is an example of some of the lead levels back in the day. And this guy who was a caster, in 1974, you take a look, in March 18, 1974, his lead level was 102. This was pretty common in the 70s, okay? This was, the lead standard was created in 1978, but this is what we dealt with. I knew this guy. I did his retirement physical a few years after I started there. Nice guy, never missed a day of work, healthiest guy, never, no problems at all in this particular case, okay? And this is out of Time Magazine. The lady in the middle there, her name is Gloyce Qualls. I knew all these ladies, I worked for all of them, okay? And Gloyce was, she was involuntarily transferred from the high-risk area to a safer workplace, okay? Where there was really no lead exposure, but her salary was cut in half. She, it was cut in half. She said, I can't afford this. I, you know, I got my family and everything else. So what she did, she went and got her tubes tied so that she produced a medical document that said, yeah, she's no longer fertile so that she can go back to make more money. Well, then she got married shortly after that. Her husband, her husband never had any kids. And so she was, she was kind of screwed. And that's one of the things that led to the losses, okay? So what did the Supreme Court say? The Supreme Court said, fetal protection policies are prohibited by Title VII of the Civil Rights Act of 1964. The OSHA Lead Standard in 1978 concluded that lead was harmful to both females and females. Title VII forbids illegal sex discrimination as a method of diverting attention from an employer's obligation to police the workplace. The court rejected Johnson Control's professed moral and ethical concerns. And the court said, decisions about the welfare of future children must be left to the parents who conceive, bear, support, and raise them rather than to the employers who hire those parents. And the Supreme Court also said, the OSHA established a series of mandatory protections which taken together should effectively minimize any risk to the fetus and newborn child. I mean, there's a thing in the OSHA Lead Standards called MRP, medical removal protection. And that includes women, okay? The MRP basically says if your lead level is high enough or you have some type of a medical problem which could be made worse or cause damage by exposure to lead, they can take you out of that lead environment with full protection of your salary and benefits until everything's better, okay? So they said, well, women are protected by the lead standard. They can go on MRP, not have to lose their salary. But at that time, the company didn't wanna do that. They just said, nope, we're not gonna let you work with lead. But the Supreme Court said, hey, you cannot discriminate. If a woman wants to work with lead, she can work with lead. So if under general tort principle, Title VII bans specific fetal protection policies and the employer fully informs that woman of the risk and the employer has not acted negligently, the basis for holding an employer liable seems remote at best. So what is the company supposed to do? The company is supposed to comply with safety and health laws and regulations. They have a duty to warn and they have a duty not to be negligent. What are the implications? Implications are employers cannot protect fetuses more than its workers. You can't ask waivers, okay? In other words, you can't just have them sign a document saying that they're assuming the risk. You can't ask for medical certifications of infertility. You can't discourage certain jobs and you cannot minimize or ignore reproductive risks to males. The lead standard basically said, hey, we understand that lead can impair the fertility of men. And if a male lead worker says, I think this is messing up with my sperm, guess what? The company has to pay for a sperm test. You have to reduce exposure levels safe for all. You need to provide warnings to male workers. Remember, assumption of risk, you can't do that. Now, it may protect the company from legal actions from the employee. Now, the first statement, reduce exposure to level safe for all. What's interesting is NIOSH came into the company and they did a health hazard evaluation in the late 90s. In my conversations with the PhD that was running that show, she basically said, well, you know, doctor, there is no safe lead level in the human body. Any lead level is unsafe at all. And Nash really didn't find a whole heck of a lot in that particular health hazard evaluation, but that's the direction they're going. In fact, the lead standard right now is obsolete. Currently, the lead standard is being rewritten, okay? They've had their public comments and we'll probably have an advance notice of those rulemaking coming up soon. And, you know, we'll see what happens with the new lead standard. The current lead standard says, if you have a lead level of 60 or an average of 50, they have to take you out of lead until your level goes down. The state of Michigan has already changed that. In Michigan OSHA, if you hit 30, you have to be out of lead until you go down to 15 for two tests in a row. What Clary also Johnson Controls is doing, same thing. If you hit 30, we take you out of lead and you can't go back until you have two consecutive readings at 20 or below. Yes, Naomi? Do you know if children then have suit companies? Wait, I was just gonna get to that. I was just gonna get to that. She asked if children have suit companies yet. So what also Johnson Controls is doing now is, you know, we send them out for a physical, we do some biological monitoring, we check their kidney function, stuff like that. Plus I do a telephone consultation with them. We have eight plants across the country and try to find out what's going on with these guys. There's all kinds of interesting stories. If I have time, I'll share some of them. Also, if someone has a lead level that's over 25, I do a telephone conversation and they get additional counseling as well. So they are working on it. I mean, right now, the average lead level across the country for Johnson Controls Clearyells is in the teens, okay? Compared to what you saw in the seventies, it's come down quite a bit, okay? Now, the state work comp laws may bar employees from suing their companies for injuries, but some courts have upheld the rights of their offspring to sue. The mother may have been informed and may be given a state-of-the-art PPE and may have agreed to the risk of the job, but the fetus didn't agree to that risk, okay? So having said that, in the whole time that I've been there since 1995, I am not aware of any kids suing the company. That's for my company. I don't know about anybody else, but as far as me, I haven't had to go testify in court about any of this stuff yet. So maybe it's time I retire. So we'll see. Here's another case, Young versus UPS. Young was a lady. She was a part-time delivery driver. UPS jobs, they require lifting packages up to 70 pounds. Now, UPS has an accommodation policy that covers workers with on-the-job injuries who are allowed to work with limitations. Now, she became pregnant and she received a 20-pound lifting restriction from her employer, and she received a 20-pound lifting restriction from her OB. The employer did not accommodate. So this went to the Supreme Court in 2015, and it provided a framework for pregnant employees challenging workplace accommodation policies and practices under the Civil Rights Act as amended by the Pregnancy Discrimination Act. A pregnant employee can establish a prima facie case of disparate treatment by showing she belongs to a protected class. She sought an accommodation. The employer did not accommodate her. The employer accommodated others similar in their ability or inability to work. So the end result is an employer must offer a legitimate, non-discriminatory reason for denying accommodation. The court noted that this reason must be more than an employer's claim that it's more expensive or less convenient to add pregnant women to the categories of those whom the employer accommodates. They did not clarify if the employers must provide workplace accommodations to pregnant employees in the same manner they provide accommodations to employees who are injured on the job. So that's kind of what the whole point was. She was saying that, hey, you're accommodating these people who have work-related injuries. You have to accommodate me. And the court says, well, yes, you have to be accommodated somehow, but they didn't tell them exactly how. Now what's happening state by state, different states are providing various pregnancy non-discrimination laws, okay? So what are some of the employer obligations? What are employer duties? Well, employer has to develop educational programs for at-risk employees. They have to operate surveillance programs for adverse reproductive outcomes in its employees. They have to create a policy to link employee removal from specific work activities based on hazard. Now, employers are responsible for training and protecting their workers. Employees are responsible for learning about the hazards in their workplace. They're responsible for using protective equipment. They're responsible for following proper work practices. There should be another bullet point under employer's responsibility. The employers are responsible for making sure their employees, for keeping their employees accountable for this, okay? You know, one of the examples I can give you, one of my plants had a lot of problems. People's lead levels were all over the place and couldn't figure out what to do. For example, I had the guys that were doing emergency welding and they claimed that, well, I don't have access to the welding pappers. So they would weld in the lead plant just using a welding helmet. And guess what? The lead levels were all over 30. Eventually, what happened was they got a new safety guy there just a few months ago. And at one time, we had about 70 people whose lead levels were over 25. And now we have 22 that are around 25 and the numbers are going down. It's because they have a new safety person there. He's holding these guys accountable. In other words, they're not coming up with anything brand new. They're just, you know, you hear all kinds of goofy. I had one guy, I did my interview with him and he was convinced that the water in the showers was contaminated and taking showers was increasing his lead level, you know. And the company's, well, that's a bunch of baloney. That's ridiculous. You know, and I told the guy, I made the company, I said, test the water, prove him wrong. Prove him wrong. That's what you have to do. There was another guy, I don't know if you've heard of him, but he's a guy who's been around for a long time. There was another guy, he was wearing a negative pressure respirator and he liked to smoke. So what he did was he drilled a little hole in his respirator that he could fit the cigarette in. And his, you know, his comments were, well, you know, when I'm not smoking my cigarette, I put a piece of tape over it. And when I am smoking the cigarette, the cigarette fits firmly in that hole. So no lead can get in past the, you know, past the cigarette. So people, and the thing is though, you know, people saw him doing this, but nobody, nobody caught him. No one stopped him. Well, that's true. That's true. That's true. This is true. You also have to think about take home exposure, exposing family members to workplace hazards via wearing or taking home contaminated clothing or boots, going home with residual contamination on his skin or hair, taking home contaminated items. Some people don't like to take showers at work. You know, OSHA says you have to offer them the shower and the company has a policy, you shall take a shower before you go. Some people don't like to do that. And they try to sneak out without taking a shower. Some people don't like washing their hair. So, and it's like, you gotta hold them accountable. You gotta make sure that they do all these things. Whenever I do these interviews, these little console, the telephone consoles, I always ask them, do you have little kids at home? If they have a, you know, one, two year old, three year old, you know, these kids are always sticking everything in their mouth. And I tell them, leave your shoes by the outside, by the door, don't wear your shoes inside because the kids are gonna get, and I tell them, when your kid goes to see the pediatrician, make sure you tell them you work in a lead foundry and a lead factory so that they can test the kids. Because even if you're, like you don't wear your street shoes into the plant, but you have to wear them from the front door to the locker room. And guess what? You're gonna get lead on those shoes. So I tell them, just leave the shoes by the door. Make sure you take your shower. Make sure that you, you know, you take your clothes off, you know, when you get home, so you're not contaminating anything, okay? You gotta remember occupational exposure standards. Consider only healthy adults. Impacts on kids, the ill, the elderly are ignored. Occupational exposure standards are based on an eight hour workday. Effects may differ with prolonged exposure. Are you okay with the time? Okay. I'm gonna go over some clinical guidelines. Okay, very good. Okay, question number three. Doctor, I'm pregnant. Can I keep working? How long can I work? Do I need any work limitations? Once again, you know, what does the scientific literature say? You have to understand the work of the employee. I mean, you know, if the person says I'm a packer, what does that mean? You know, oh, I lift 10,000 pounds a day. Well, yeah, with a forklift, you know what I mean? What are the actual specific exposures? Now, ACOG has some guidelines for job continuation. And in an uncomplicated normal pregnancy, the following work schedule restrictions may be followed. And they follow the Department of Labor definitions, okay? Sedentary activities until 40 weeks or beginning of labor. Sedentary is defined as not lifting more than 10 pounds and you're sitting at least 51% of the time. Light activities until 38 weeks. That's lifting 11 to 25 pounds. Moderate activities until 32 weeks. That's 26 to 50 pounds. Heavy activities until 26, until, no, no, no, no, no, until 26 weeks. Heavy activities until 26 weeks. That's 51 to 100 pounds. And they're saying you could do very heavy activities until 20 weeks. That's greater than 100 pounds. That's out of ACOG. You know, and they have all kinds of other guidelines that you could look at if you're trying to figure out, well, what type, you know, pregnant lady, what type of limitations should I put on her? You know, these are the guidelines from ACOG. Now there's, AHRQ is the Agency for Healthcare Research and Quality. Unfortunately, they were defunded in 2018, but they did do quite a bit of research on some of the studies on pregnant ladies. And they would come up with, they came up with some references that long working hours, there was a low to moderate risk for low birth weight, small for gestational age, intrauterine growth restriction and preterm birth. There was a shift work and night work. It was associated with a low to moderate risk for adverse pregnancy outcomes. Prolonged standing over three hours. In general, prolonged standing for greater than three hours per day results in no more than a low to moderate risk, adverse risk for adverse pregnancy outcomes. And, you know, you could just go ahead and read that. It just, it gives you some documentation of what's in the literature. There is a guideline for lifting. This is, I don't have the directions. If you want the directions, as far as this is steps in determining the recommended weight limit based on the, based on the level of pregnancy, just Google lifting guidelines during pregnancy NIOSH, NIOSH lifting guidelines during pregnancy. This table will show up. It'll give you the actual directions on how to work it. A little clinical hurl. I've seen several referred patients who present their employer with a slip from the provider stating no chemical use allowed, avoid exposure to all chemicals. You know, don't do that. Please don't, it's illogical. Remember water and air chemicals. It provides no guidance to the employer, puts worker in an awkward position of arguing with the employer, which as far as which chemicals are safe, it could get the employee sent home. It may increase anxiety and liability. ACOG has a committee opinion from April of 2018. It's employment considerations during pregnancy and the postpartum period. It actually gives, there's a little area that says how to write work restrictions during pregnancy. Now in 2017, Massachusetts backed protections for pregnant workers. In 2018, Pregnant Workers Fairness Act was created. And they said, pregnancy is not a disability. It's not an ADA issue, but it does require accommodations. If there's light duty for any other act limitation, then you have to have light duty for pregnant. So in other words, pregnant ladies are entitled to reasonable accommodation. So if you have light duty for workers who are injured, you have to be able to provide the same type of light duty or accommodate light duty for pregnant ladies, okay? There's NIOSH topics. You looked up reproductive health in the workplace and NIOSH has a lot of good information, both for workers as well as for physicians. And some of those topics include specific job categories. Some of the topics include specific work exposures. And they do a pretty good job as far as being a resource. Like if you don't know, if you don't know what are the risks associated with lead or truck driving, that you should be able to find that topic in the NIOSH reproductive health in the workplace. Do you have a second for a question? Sure. The audience, does NCOG make any recommendations for heat stress during pregnancy? I don't know. I'll be honest, I don't. That's a good question. I know that NIOSH is working on a heat stress standard and they change a little bit, so it's pretty similar, but let me put that as a do-well question. Okay. Next question. When you mentioned accommodation similar to those with injuries, is that job-related injury? We usually treat related injuries different than non-work related. Yeah, correct. If the employer has any type of an accommodation program, then you have to include pregnant women. So some companies say, okay, if you can't do the job, we're not gonna accommodate you at all. That's what some companies do. Most companies accommodate job-related injuries because they don't have to worry about lost time and all that other stuff. But the states and the Supreme Court are saying that, you know, if you accommodate work injuries, you gotta be able to accommodate the pregnant ladies too. Here's, you know, ACOG has all kinds of educational guides. I honestly don't know about heat. That's a very good question. Any other questions? One more from the audience. Dr. Peters, I understand that pregnant workers are covered under the Pregnant Workers Fairness Act rather than ADA, and the employer can refuse an accommodation if it presents a hardship. Can the employer also refuse an accommodation if it impacts the essential function of the employee's job? If the employer is accommodating any other type of limitation, they have to accommodate the pregnant worker, okay? If their policy is they don't accommodate any limitations, I don't know if that applies to the Pregnancy Act. I don't know. So I think that's a good basis. These become medical legal in that we, as physicians, can only advise the company of what to do. Exactly. As a physician, you know, I'm going to give an opinion. Well, this person is pregnant at, you know, 36 weeks, and I feel that these are reasonable accommodations. She may not be able to perform the essential functions of her job. A, B, and C. A, B, and C. Exactly. But she can perform these other parts, okay? It's still evolving. You know, these Pregnancy Act things are just so much these Pregnancy Act things are just, it's just been the last five years or so. And, you know, who knows what's going to happen? It's like when the ADA first came out, nobody knew what the hell that was going to be. Right. Okay. Anything else? All right, thanks a lot. Thank you.

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