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

Occupational/Exposure History

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

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

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

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

Occupational/Exposure History

Identification of a problem or documenting exposure in your patient may benefit others

Increased usefulness with EMR

Occupational/Exposure History

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

Occupational/Exposure History

• Plan for surveillance exams

• Establish the basis for compensation

Occupational/Exposure History

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

Occupational/Exposure History

Key Concepts

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

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)?

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

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

Biological Plausibility of the Exposure and Symptoms

• Basic toxicology still holds:

– Symptoms consistent with route of entry/absorption

Biological Plausibility of the Exposure and Symptoms

• Effects of removal, relocation, return

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?

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