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

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?
It Kills Humans

• 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 its many problems.

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, Hodgkins Disease, Non-Hodgkins
  Lymphoma, Ischemic Heart Disease, Multiple
  Myeloma, Parkinsons Disease, Peripheral
  Neuropathy Also associated with diabetes
  late-onset. Porphyria Cutanea Tarda,
  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.

16
(No Transcript)
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.

18
(No Transcript)
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
• lt ASK WHICH TEST ARE FOR YOUR CONDITION/s AND
  HAVE THEM RUN THE DEFINATIVE TESTgt

27
Advice to the Veteran

• Write down/List all of your medical problems If
  wondering what to write down - Dont think about
  it, dont ask yourself if you should or
  shouldnt, if this is something they want or they
  dont want just write it down!

28
More advice

• Do not take your medical providers at their word.
  Many times they will say oh thats ok it is just
  arthritis or thats 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 VAs 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.