What did it do to them?

1. Agent Orange and End Organ DiseaseMy experiences as a veteran, patient, and a health care provider.Hans White, PA-C

2. What did it do to them?

3. What Does Agent Orange Do? • After Agent Orange exposure, this dangerous chemical (Dioxin) begins to accumulate in the fatty tissues of the body and stays in a person's body for a long period of time. It can cause many diseases and in the end could cause death in humans. One of the most devastating disease is type II diabetes and diabetes will be the root cause of every other problem the veteran could and will have. • For our purposes I follow the link from Agent Orange to Diabetes and it’s many problems. It Kills Humans

4. Agent Orange • Agent Orange is an herbicide that was used from the 1940s through Vietnam War in the 1960s. Agent Orange is a defoliant and herbicide when sprayed on plants, it causes them to die. Scientists found that it contains a very dangerous dioxin. It was later suspected that people who were exposed to Agent Orange, including American soldiers, were at risk of dioxin poisoning.

5. Agent Orange Act • In 1991, the United States Congress passed the Agent Orange Act, which stated Vietnam War veterans who were diagnosed with medical conditions stemming from Agent Orange exposure would be treated and compensated.

6. Agent Orange Presumptive Diseases • Although there are many medical problems related to Agent Orange, the VA only considers the following listed medical problems to Agent Orange as presumptive diseases. • Amyloidosis, Chronic B-cell Leukemias, Chloracne (or similar acneform disease), Diabetes Mellitus Type 2, Hodgkin’s Disease, Non-Hodgkin’s Lymphoma, Ischemic Heart Disease, Multiple Myeloma, Parkinson’s Disease, Peripheral Neuropathy **** Also associated with diabetes late-onset. **** Porphyria CutaneaTarda, Prostate Cancer, Respiratory Cancers (includes lung cancer), Soft Tissue Sarcomas  

7. What is Diabetes Mellitus? • Diabetes mellitus is characterized by high blood sugar levels that result from defects in insulin secretion, or its action, or both. • Elevated levels of blood glucose levels are tightly controlled by insulin, a hormone produced by the pancreas. Insulin lowers the blood glucose level. When the blood glucose elevates (for example, after eating food), insulin is released from the pancreas to normalize the glucose level. In patients with diabetes, the absence of insufficient production of or lack of response to insulin causes high blood sugars (hyperglycemia). Diabetes is a chronic medical condition, meaning that although it can be controlled, it lasts a lifetime.

8. What are the chronic complications of diabetes? • Diabetes complications are related to blood vessel diseases and are generally classified into small vessel disease, such as those involving the eyes, kidneys and nerves (microvascular disease), and large vessel disease involving the heart and blood vessels (macrovascular disease).

9. Diabetes Diabetic Retinopathy Leads to blindness Ischemic Heart Disease (heart attack/stroke) Diabetic Nephropathy Kidney disease leads to dialysis Diabetic Peripheral Artery Disease Diabetic Neuropathy Leads to loss of sensation Leads to lost toes/feet/legs

10. Complications of DM - Eye • Eye Complications • The major eye complication of diabetes is called diabetic retinopathy. Diseased small blood vessels in the back of the eye cause the leakage of protein and blood in the retina. Spontaneous bleeding from the new and brittle blood vessels can lead to retinal scarring and retinal detachment, thus impairing vision. • Approximately 50% of patients with diabetes will develop some degree of diabetic retinopathy after 10 years of diabetes, and 80% of diabetics have retinopathy after 15 years of the disease. Poor control of blood sugar and blood pressure further aggravates eye disease in diabetes. • Cataracts and glaucoma are also more common among diabetics. It is also important to note that since the lens of the eye lets water through, if blood sugar concentrations vary a lot, the lens of the eye will shrink and swell with fluid accordingly. As a result, blurry vision is very common in poorly controlled diabetes.

11. Complications of DM-Kidney • Kidney damage from diabetes is called diabetic nephropathy. The kidneys lose their ability to cleanse and filter blood. The accumulation of toxic waste products in the blood leads to the need for dialysis. Dialysis involves using a machine that serves the function of the kidney by filtering and cleaning the blood. The progression of nephropathy in patients can be significantly slowed by controlling high blood pressure, and by aggressively treating high blood sugar levels.

12. Complications of DM-Nerve Damage • Nerve damage from diabetes is called diabetic neuropathy. In essence, the blood flow to the nerves is limited, leaving the nerves without blood flow, and they get damaged or die as a result . Symptoms of diabetic nerve damage include numbness, burning, and aching of the feet and lower extremities. In later stages a complete loss of sensation in the feet occur, patients may not be aware of injuries to the feet. Because of poor blood circulation, diabetic foot injuries may not heal. Sometimes, minor foot injuries can lead to serious infection, ulcers, and even gangrene, necessitating surgical amputation of toes, feet, and other infected parts.

13. Complications of DM-Nerve Damage Cont. • Diabetic nerve damage can affect the nerves that are important for penile erection, causing erectile dysfunction (ED, impotence). Erectile dysfunction can also be caused by poor blood flow to the penis from diabetic blood vessel disease. • Diabetic neuropathy can also affect nerves to the stomach and intestines, causing nausea, weight loss, diarrhea, and other symptoms of gastroparesis (delayed emptying of food contents from the stomach into the intestines, due to ineffective contraction of the stomach muscles). • The pain of diabetic nerve damage may also improve with better blood sugar control, though unfortunately blood glucose control and the course of neuropathy do not always go hand in hand.

14. Diabetic Vascular Disease Diabetic vascular disease refers to varying medical issues with veins and mostly arteries in the development of blockages in the arteries, sometimes called “hardening of the arteries”. This could and in the end develop serious health conditions, including blindness, severe kidney disease, stroke, heart attack, or sores in your feet. Eventually, if you develop dead tissue, which is known as gangrene, it could lead to infection and ultimately to amputation.

15. What is atherosclerosis? • Atherosclerosis is a gradual process whereby hard cholesterol substances (plaques) are deposited in the walls of the arteries. Cholesterol plaques cause hardening of the artery walls and narrowing of the inner channel (lumen) of the artery. This process usually begins early in life, However, is escalated by other human issues such as Agent Orange and diabetes. Therefore, many adults typically are unaware that their arteries are gradually accumulating cholesterol plaques. When it becomes advanced with aging, it causes critical narrowing of the arteries resulting in tissue ischemia (lack of blood and oxygen). • Arteries that are narrowed cause diseases in different organs. For example, the coronary arteries which supply blood to the heart muscles can lead to heart attacks. The carotid and cerebral arteries (arteries that supply blood to the brain) can lead to strokes and transient ischemic attacks (TIAs). The lower extremities can lead to pain while walking or exercising (claudication), deficient wound healing, and/or leg ulcers.

17. Heart Disease • Heart disease is the leading cause of mortality in the Western World. The term coronary heart disease also referred to as ischemic heart disease which by itself is a presumptive disease associated with Agent Orange refers to a condition whereby the heart itself is deprived of an adequate oxygen supply. It is usually caused by he narrowing of coronary arteries. Whilst the function of the heart is to pump oxygenated blood around the body, the heart tissue itself must be supplied with oxygenated blood to survive. As the fatty deposits accumulate, the arteries become narrowed and the amount of blood that can pass through them is reduced. If a coronary artery becomes blocked, the patient will suffer a heart attack and if the heart is deprived of oxygen for long, irreversible damage to the muscle will result. It is a common cause of congestive heart failure. The risk of the condition increases with: age; a familial history of the disease (i.e. a genetic component); smoking; dietary factors (notably, a high cholesterol diet); diabetes; and high blood pressure.

19. VA Form 21-0960A-4 Oct 2012

20. Conditions that increase risk for coronary heart disease • Sleep apnea. This disorder causes you to repeatedly stop and start breathing while you're sleeping. Sudden drops in blood oxygen levels that occur during sleep apnea increase blood pressure and strain the cardiovascular system, possibly leading to coronary artery disease. • Obesity. Excess weight typically worsens other risk factors. • Smoking. Nicotine constricts your blood vessels, and carbon monoxide can damage their inner lining, making them more susceptible to atherosclerosis. The incidence of heart attack in women who smoke at least 20 cigarettes a day is SIX TIMES that of women who've never smoked. For men who smoke, the incidence is TRIPLE that of nonsmokers. • Metabolic syndrome — a cluster of conditions that includes elevated blood pressure, high triglycerides, elevated insulin levels and excess body fat around the waist — increases the risk of coronary artery disease.

21. Procedures to restore and improve blood flow • Angioplasty and stent placement (percutaneous coronary revascularization). This can be done in the legs too. • Coronary artery bypass grafting (CABG) surgery. Bypass grafting can also be done to the arteries of the legs to restore proper flow to them.

22. Complications of DM -Peripheral Vascular Disease • Peripheral vascular disease (PVD) refers to diseases of the blood vessels (arteries and veins) located outside the heart and brain. While there are many causes of peripheral vascular disease, doctors commonly use the term peripheral vascular disease to refer to peripheral artery disease (peripheral arterial disease, PAD), a condition that develops when the arteries that supply blood to the internal organs, arms, and legs become completely or partially blocked as a result of atherosclerosis. This often leads leg and foot ulcers to worsening of nerve damage, and ultimately the loss of toes, feet and legs.

23. Atherosclerosis of the legs

24. Medical tests your doctor may perform • Cardiac conditions: • Electrocardiogram (ECG) and Holter(an ECG that you wear around for a day or two). • Echocardiogram. This is an ultrasound of your heart that looks at the structure. • Exercise Stress test.This can also be done without exercise. • Cardiac catheterization or angiogram.**GOLD STANDARD** • Heart scan. Computerized tomography A CT coronary angiogram • Magnetic resonance angiography (MRA). This procedure uses MRI technology, often combined with an injected contrast dye.

25. Testing cont. • Peripheral Vascular Diseases: • Ankle Brachial Index (ABI) and/or Doppler Flow Studies. These are tests that are done if your legs hurt when you walk and your calves cramp. • Duplex Doppler Ultrasound • Venography • MRI/MRA • ABI

26. Testing • Basic Testing • Laboratory • Basic Radiology - X ray • Advanced imaging – CT, MRI, MRA, PET and more Lung problems your provider may order PFT < ASK WHICH TEST ARE FOR YOUR CONDITION/s AND HAVE THEM RUN THE DEFINATIVE TEST>

27. Advice to the Veteran • Write down/List all of your medical problems – If wondering what to write down - Don’t think about it, don’t ask yourself if you should or shouldn’t, if this is something they want or they don’t want – just write it down!

28. More advice • Do not take your medical providers at their word. Many times they will say “oh that’s ok it is just arthritis” or “that’s just part of getting older”. Be proactive, ask questions • If you disagree seek second opinion. • Request specialist referral • Ask for and keep copies of all visits and tests

29. Veterans duty • Go on line to the VA sites, Best site is: 38 CFR C SHEDULE FOR RATING DISABILITIES. Look up your medical issues, read the criteria, make copies and bring them to you health care providers. • Most civilian providers know nothing about VA disability or Social Security disability and want nothing to do with it.

30. Civilian vs.VA Health Care • There is a difference; however not for long.

31. Let me tell you about Health Care Providers and our health care system! • Most have the best intensions, many do not • Some are smart, many are not. • For most people the system no longer allows for personalized in-depth care

32. Let me tell you about the VA • Medical care at the VA is just about the same as in the private sector – not !!! • Many providers, ancillary staff from nursing to house keeping are generally proficient and caring. • Administration; mid-level and down ward are just like you and me. Some senior administrators do the best they can in a system that is dysfunctional. • Overt problems consist of long waits for appointments, changing providers, getting tests approval and appointments in a timely manner. • Covert problems – well you hear the news, VA sending to out side providers will make it worse.

33. Let me tell you about the VAsome more My story Thank you, thank you, thank you Mrs. VanVliet my VA rep. I could not and probably would not have completed the process without her. I have learned much from her and I, my family and my veteran patients thank you. My fault – Disorganized and lazy. And what is the VA’s fault

34. EVERYTHING • EVERYTHING

35. My story some more My first and only visit to the VA; courteous, professional and strange. Hearing test – fell asleep, need two hearing aids, not service connected One provider one visit one day One fine day; I come home and find a opened envelope from the VA. I ask my wife what it was and she said “ I looked it over and could not understand it, it is all confusing”. 90%, 90% of what?

36. more • Over the following month I received many more envelopes from the VA – confusing • I complained to anyone listening about the stupidity of the VA • I find out about e-benefits, sign up(what a strange site) and recheck every so often. Development Letter Sent Two weeks later the same 4 weeks later the same, I called told they wanted something however he did not know what. He will make a note to have the letter sent again.

37. more • Development letter received, something's real other things not so real- gave them what they wanted • Telephone calls Idaho, Mississippi and Florida • Provider assignment • Due date May 2014, Due date November 2014, Due date sometime 2015

38. Reality • I and many others complain about the VA medical system, much is justified although not all. • Many men and women have received help relieving themselves and family from significant burden.

39. Thank you • From the bottom of this old Veterans heart; You have impacted many lives and I know you will do so in the future. • I thank you all for what you do.