Veterans Exposure Concerns: The Occupational and Environmental Medicine History

1. Veterans Exposure Concerns: The Occupational and Environmental Medicine History Debra Milek M.D., Ph.D., M.P.H. Department of Preventive Medicine/Occupational and Environmental Medicine

2. Occupational/Exposure History • Single most important instrument for obtaining information on the role of occupational and environmental factors in causing disease

3. What is an occupational/environmental medicine evaluation? • Typical medical history plus an occupational history • Includes an environmental exposure assessment -----from all possible sources (military, work, home, hobbies, significant other, neighborhood) • Helpful to have a standardized questionnaire to obtain the factual outline of exposures

4. Occupational/Exposure History • Greater emphasis in determining the etiology of complaint • Occupational diseases frequently are identical in symptoms and pathology to those of non occupational origin • E.g.Occupational asthma, solvent encephalopathy, peripheral neuropathy There may be recognizable and preventable causes or exposures

5. Occupational/Exposure History • Treatment is likely to include exposure reduction, elimination or protection • In some cases, this may mean inability to return to the same type of work

6. Occupational/Exposure History Identification of a problem or documenting exposure in your patient may benefit others Increased usefulness with EMR

7. Occupational/Exposure History • Given an exposure history, you can probe for symptoms or signs otherwise not apparent to your patient or you

8. Occupational/Exposure History • Plan for surveillance exams • Establish the basis for compensation

9. Occupational/Exposure History • To allay fears, address concerns, and support lifestyle modifications that could impact health

10. Occupational/Exposure History Key Concepts

11. CONCEPTUALIZING THE OCCUPATIONAL/EXPOSURE HISTORY • Review the exposure history with the patient, amplifying, clarifying • Go into greater detail where there are symptoms or concerns (the patient’s or yours) • Who=Job title and duties • What=The exposure of concern • When =Date(s) when the exposure occurred AND duration • Where=Location and location of individual relative to exposure • How=Route of entry (dermal, inhalation, ingestion; ventilation, personal protective equipment) • Why=Accident, acute or chronic exposure

12. Look For A Temporal Relationship • Between the introduction of a new toxic exposure, accident, injury or stressor Chemical, physical, biological, psychological And the onset of illness EXPOSURE MUST PRECEDE THE ILLNESS • Did symptoms begin shortly after starting a new assignment, task, location or change in the way it’s done or change in the environment or was there an incident? • Or doing the same job for many years (cumulative exposure)?

13. Biological Plausibility of the Exposure and Symptoms • What is already known? • Easier if previously diagnosed relationship between exposure and disease • But be observant and record….. • Many chemicals untested for toxicity • >60,000 new/year industrially • Unfamiliar elements of foreign conflict, biologicals • May diagnose something previously unrecognized

14. Biological Plausibility of the Exposure and Symptoms • Important component of biological plausibility is: Dose-Response • Greater likelihood if disease occurs more commonly in more heavily exposed. Inquire about • Extent of exposure (Amount, Duration) • Proximity • Personal protective equipment • Others affected • Allows for RISK STRATIFICATION • Caveat: Differing susceptibilities

15. Biological Plausibility of the Exposure and Symptoms • Basic toxicology still holds: • Symptoms consistent withroute of entry/absorption

16. Biological Plausibility of the Exposure and Symptoms • Effects of removal, relocation, return

17. You can get more information later • Exposure data may be available from air sampling or even personal sampling • USACHPPM as a resource in the future?

18. And now for the details specific to Iraq and Afghanistan….