Veterans Exposure Concerns: The Occupational and Environmental Medicine History

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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

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Occupational/Exposure History

• Single most important instrument for obtaining
  information on the role of occupational and
  environmental factors in causing disease

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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

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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

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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

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Occupational/Exposure History

• Identification of a problem or documenting
  exposure in your patient may benefit others
• Increased usefulness with EMR

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Occupational/Exposure History

• Given an exposure history, you can probe for
  symptoms or signs otherwise not apparent to your
  patient or you

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Occupational/Exposure History

• Plan for surveillance exams
• Establish the basis for compensation

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Occupational/Exposure History

• To allay fears, address concerns, and support
  lifestyle modifications that could impact health

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Occupational/Exposure History

• Key Concepts

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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 patients or yours)
• WhoJob title and duties
• WhatThe exposure of concern
• When Date(s) when the exposure occurred AND
  duration
• WhereLocation and location of individual
  relative to exposure
• HowRoute of entry (dermal, inhalation,
  ingestion ventilation, personal protective
  equipment)
• WhyAccident, acute or chronic exposure

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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
  its done or change in the environment or was
  there an incident?
• Or doing the same job for many years (cumulative
  exposure)?

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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
• gt60,000 new/year industrially
• Unfamiliar elements of foreign conflict,
  biologicals
• May diagnose something previously unrecognized

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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

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Biological Plausibility of the Exposure and
Symptoms

• Basic toxicology still holds
• Symptoms consistent with route of entry/absorption

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Biological Plausibility of the Exposure and
Symptoms

• Effects of removal, relocation, return

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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?

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• And now for the details specific to Iraq and
  Afghanistan.