A Crane Operator Ten Weeks After Myocardial Infarction Wants an Unrestricted Certificate
A 52-year-old gantry crane operator at a container terminal in Surabaya has worked 24 years for the company. Ten weeks ago he had an anterior STEMI treated with primary PCI and one drug-eluting stent; ejection fraction is 40%, there is no residual angina, and he takes aspirin, ticagrelor, bisoprolol, atorvastatin and ramipril. The job requires climbing a 22-m ladder, working 12-hour rotating shifts including nights, and uninterrupted vigilance while moving containers above people. He wants to return immediately because shift allowance and overtime make up 40% of his pay. His cardiologist has written 'may resume normal activity'. HR asks the occupational physician for a 'fit' certificate for the port authority, noting that a crane operator at a neighbouring terminal died at the controls two years ago and the union is watching. His fasting glucose is 8.9 mmol/L, BMI 32, and he has not had an exercise tolerance test since discharge.
1. How should the physician reach a fitness-for-work decision, and what should the certificate say?
Read the worked answer
Reasoning. 'May resume normal activity' is a clinical opinion about ordinary living; it is not a fitness-for-work determination. The occupational question is whether the risk of sudden incapacitation is acceptable in a job where incapacitation would drop a container on people, and whether he can physically climb 22 m and sustain vigilance through a 12-hour night shift. Ten weeks after an anterior STEMI with an ejection fraction of 40% and no post-discharge functional test, that risk is not yet characterised. Guideline practice for safety-critical work is to demonstrate adequate functional capacity - typically an exercise tolerance test showing at least about 7 METs without ischaemia, significant arrhythmia or an abnormal blood-pressure response - and to review the medication burden: a beta-blocker blunts the tachycardia that would otherwise warn of ischaemia, and ticagrelor raises bleeding risk after any fall or impact.
Decision. Not fit without restriction at this point. I would certify: 'Temporarily unfit for safety-critical crane operation, for climbing to height, and for night shift. Fit for restricted day-shift duties (yard planning, despatch, documentation).' Review in 4–8 weeks against an exercise tolerance test and a cardiology report addressing ischaemia, arrhythmia and functional capacity.
If he later meets criteria. A phased return - day shifts first, then nights only after a specific review of sleep and alertness - with a defined review date, is safer than an immediate return to the full roster. The certificate must state restrictions explicitly and never simply say 'fit'.
2. How should his diabetes, obesity and shift-work pattern influence the assessment and the plan?
Read the worked answer
Reasoning. A fasting glucose of 8.9 mmol/L with a BMI of 32 indicates inadequately controlled type 2 diabetes, which is itself a cardiovascular risk factor and, in a shift worker, a source of hypoglycaemia and alertness problems. His current regimen does not obviously include insulin or a sulfonylurea, so hypoglycaemia risk today is low - but that is exactly why the medication list must be rechecked at each review, because a future intensification of treatment changes the fitness picture.
Shift work. Night shifts disrupt circadian rhythm, worsen glycaemic control and increase fatigue-related error. Combined with a lone cabin, a 22-m ladder and heavy machinery, night work adds risk that is not captured by a cardiology opinion. Until his cardiac status is defined, night shifts should be excluded.
What I would do. Refer to endocrinology for HbA1c and a treatment plan, and ask the dietitian to address meal timing across shifts. Recommend self-monitoring of glucose, with a rule about not operating if glucose is low, and ensure he is not working alone in a remote cabin until control is stable. Address weight and smoking status through the workplace health promotion programme, and document that these are risk-modification measures, not conditions of continued employment. A review at three months should re-examine both cardiac and metabolic status together, because the two interact.
3. HR wants a one-line 'fit' certificate for the port authority, and the worker is threatening to complain. How should the physician manage the communication and the documentation?
Read the worked answer
With the worker first. I would meet him, explain the reasoning in terms of the job rather than in terms of his heart, and show him that the restricted certificate protects his employment while the cardiac picture is clarified. Offer the referral for the exercise test and explain the timeframe and the criteria for returning to the crane. Giving him a copy of the restrictions and a review date turns a refusal into a plan.
What the certificate says. 'Fit for restricted duty: day shift only, no work at height, no safety-critical crane operation, review on [date].' A one-line 'fit' would be false and would transfer the risk of a fatal incident to the doctor who signed it. If the port authority's form has no field for restrictions, I would attach a covering letter rather than compress the finding into the wrong box.
Confidentiality. The diagnosis and the ejection fraction stay in the medical record; the employer receives the restrictions and the review date, with the worker's consent, as required by Permenkes 36/2012.
If the employer proceeds anyway. I would put the recommendation and the reason in writing to HR and the K3 committee, keep a copy, and state that assigning him to the crane against medical advice places other workers at risk. Under UU 1/1970 the employer carries the duty to protect; the occupational physician's duty is to make the risk visible and to refuse to paper over it. Complaints from the worker or the union are best answered by showing the clinical criteria and the review pathway.