Abstracts

Rationale: Safety-sensitive positions are ones where impaired performance could result in a significant incident affecting the health of the patient or others. People with epilepsy (PWE) are successfully employed as police officers, firefighters and other high risk jobs. Under the American with disabilities act employers may not exclude employees for safety reasons unless there is specific medical documentation that the individual "would pose a direct threat to health and safety." Neurologists are sometimes asked to determine fitness to work in PWE. We report two cases of PWE in high-risk jobs to illustrate the decision making process involved in these determinations. Methods: Case 1A 28 year old right-handed female police officer with epilepsy since age 9. Seizures characterized by taste of blood in her mouth followed by staring and generalized tonic-clonic (GTC) activity. Seizures associated with sleep deprivation and menses. She is on LEV and her last seizure was at age 19 after attempting to wean off. Denies side-effects. No substance use. Had a speech impediment as a child, has a cousin with epilepsy, no other risk factors. Exam nonfocal. Last brain MRI showed increase signal intensity and atrophy involving the right hippocampus with no interval change versus brain MRI done 14 years earlier. EEG at outside hospital 10 years prior showed multifocal discharges greater in right parietotemporal region. EEG's for last 3 years normal. Patient works as a police officer in a hospital and remains seizure and incident free.Case 2A 21 year-old right-handed competitive swimmer at university admitted after being extracted from a pool where he had a 1 minute GTC seizure with shoulder dislocation and pneumonitis. First unprovoked seizure occurred 3 months prior, also while swimming. He denied any auras or risk factors for epilepsy. He was seen by local neurologist and advised to start LEV and stop swimming. Patient did not do either. He sought a second opinion a few days before last seizure, and was advised again to start LEV, stop swimming, and driving for 6 months. His exam was nonfocal. inpatient 3-Tesla brain MRI and continuous video EEG normal. He was started on LEV and urged to stop swimming, no driving for 6 months. Results: Cases 1 and 2 illustrate PWE in high risk jobs who could pose a threat to themselves and others. We propose a systematic approach to determine job fitness in PWE: 1. Request from employer job description, duties, work scheulde, and breaks to take medication. 2. Obtain detailed history and exam including, seizure semiology, presence of auras, precipitating factors, injuries due to seizures, AED adherence, side-effects, and levels. Review EEG and brain MRI. 3. Ascertain social history including stressors and substance use. Opinions must be based on "a reasonable degree of medical certainty" or at least 51% probability. Subject in Case 1, works 9-5, occasional overnight shift, seizure free for 10 years, aura precedes seizure, precipitants are sleep deprivation and menses, no injuries, AED levels consistently therapeutic, no side effects, nonfocal exam, last 3 EEGs normal, brain MRI stable, no substance abuse. Determination: Low risk recurrent seizure, may continue work as police officer. Case 2: Competitive swimmer, daily training, lifeguard present, no aura before seizure, two near-drowning events, dislocated shoulder, pneumonitis, non-adherence to AED, normal exam, EEG, and brain MRI, no substance use. Determination: High risk for recurrent seizure harm to self and others (may drown rescuer). No swimming. Conclusions: We propose an individualized and systematic approach to determine job fitness in PWE in safety-sensitive jobs. Funding: None