By Garry S. Moore, MD
A friend of mine used to do social security evaluations to determine disability. Patients would say, “I can’t work, I have diabetes!” Of course diabetes is a terrible disease but diabetics can still work — or can they? What are the effects of diabetes on employment and what are the effects of an occupation on the diabetic? What is the impact diabetes has on workers’ compensation?
These are questions about the forest, while most of us are looking at trees. An estimated 10 percent of workers in San Antonio have diabetes. We know our patients and their limitations, but if you step back and look at how many diabetic workers are struggling to maintain a job and maintain their health, it is a very big problem.
The adverse effects of diabetes are mostly due to hyperglycemia, but in the workplace it is the hypoglycemic episodes that cause the catastrophic events. For example, an insulin dependant diabetic may not have a commercial driver’s license. Obtaining a commercial pilot’s certificate is very difficult even for non-insulin dependant diabetics. In many jurisdictions, becoming a police officer, a fireman or even a paramedic is not an option if one requires insulin.
The more insidious effects of hyperglycemia can adversely impact cognitive performance and vision, even before permanent damage is done due to osmotic effects. The impact these have on job performance and safety can only be guessed. Imagine if an employer did post-accident blood sugar levels just as we now do post-accident drug and alcohol tests. The end organ damage associated with diabetes can affect job performance in less subtle ways, usually demonstrated best with absenteeism or “presenteeism” (being physically present for work but not productive).
Just as the diabetic is damned if they keep their sugar too high or too low, the employer is damned if the work is too sedentary and damned if it’s too physical. Most modern occupations are too sedentary. Consider a truck or bus driver who works 10-12 hours a day but burns very few calories. Office workers face similar challenges.
The sedentary life increases obesity and obesity worsens glucose control. Obesity and hyperglycemia lead to hypertrophy of tendon sheaths such that the small amount of physical work that was being done, e.g. on a keyboard, now seems to cause carpal tunnel syndrome.
Take a retail worker who typically stands for more than two hours at a time with 5 to10 minute breaks. Usually prolonged standing causes more discomfort than damage, but all it takes is a little breakdown in the skin of the feet and serious complications may follow.
A warehouse or construction worker may get plenty of physical exercise, but what if they drop something heavy on their foot? Well, they’re supposed to be wearing steel-toed boots, but the rigid steel part abrades their toes so their doctor says to get looser, softer shoes. So the toe gets crushed.
Occupational injuries are more likely to occur to extremities; diabetic neuropathy is more likely to occur in the extremities. The two can intersect with terrible consequences. In one study, close to 50 percent of non-insulin dependant diabetics had significant neuropathy after 10 years of being a diabetic. For most Americans, that means a long time in the work force with a significant neuropathy.
Believe it or not, workers’ compensation is more logical in Texas than it is in some states. A case in Georgia a few years ago involved a truck driver (with a clandestine 20-year history of diabetes) who became dizzy and nauseous. He pulled off the road and did not remember anything else, but was found a few hours later lying face down in a “diabetic coma” approximately 500 yards from the truck.
The driver was taken to an ER where the blood alcohol level was noted to be .013 and there was apparently damage to the kidneys and other organs due to exposure and immobility. His kidney and other organ damage were considered work related and compensable.
In a Louisiana case, a worker had a compensable back injury being treated with epidural steroid injections. After the second injection two weeks later, the worker suffered a “severe hyperglycemic reaction." This was apparently the first suggestion he had diabetes, so initially it appears the claimant suggested the injections caused the diabetes. His doctor later indicated otherwise.
A judge in Connecticut determined that an injury to a worker’s arm was made “substantially and materially worse” by the fact that she also had diabetes and was therefore entitled to some additional benefits. This case
was later reversed because the treating doctors could not say with certainty whether the diabetes pre-dated the
arm injury.
These are just a few of the examples of how diabetes can be a very complicated co-morbidity with a workers’ compensation claim. It has been my experience in Texas that the insurance carriers move quickly to limit their liability. For example, in the case of a crushed toe, they will accept as work related the crush, but none of the complications that may follow. This will often require a doctor to say one complication is a normal consequence of an injury and another is much less likely to have happened had the worker not had diabetes. It’s rare that medicine can be that definitive…but we are expected to be.
Dr Garry Moore is board certified in Occupational and Aerospace Medicine
and a past president of the Texas College
of Occupational and Environmental
Medicine. His training was in the USAF and he remains in the Texas Air National Guard. Dr. Moore's practice is in the Northeast side of town.
