Okay, so we're at the top of the hour, so we'll go ahead and get started. Good afternoon, everyone, and I would like to thank you for attending this session about military exposures in an era of telehealth. So some housekeeping, none of the speakers have a conflict of or financial interest to disclose, and the opinions are those of the speakers and not VA. Moving on to the agenda, so on slide three, you'll see that we do have the agenda here. My name is Dr. Shauna Smith, and I will briefly introduce military exposures and the six VA registries. We have Dr. Peter Rum, who will discuss, who is a friend and colleague of mine and also my supervisor, he will discuss deployment exposures, and some of those deployment exposures that he will discuss are Agent Orange, liver flukes, Gulf War illness, burn pits, PFAS, and K2, or readily known as Karshi Carnivite. Dr. Robertson, who is also a colleague of mine, will discuss garrison exposures, and she will also present a case study on telehealth and exposure history, as well as discuss VA and telehealth. And then lastly, we have Dr. Katz, also known as Colonel Katz, who will provide an in-depth overview of the War-Related Illness and Injury Study Center, or you all will hear me refer to that as the RISC. Okay, so the objectives for today, providers will gain an awareness of the growing importance of environmental and occupational medicine to evaluate military exposures in veterans. Registries will gain an understanding on why registries have strengths and weaknesses, and that the individual longitudinal exposure registry may help solve some of these issues, as well as telehealth can handle some, but not all of the issues with evaluating a veteran with possible toxic exposures. This session will help with triaging additional tests or consults as needed based on history. So of course, this is my biography, I will not waste the time to read it to you all, because you can always get to know me later. But I do want to point out that I do have greater than 19 years of experience in nursing and public health. I have been a communicable disease specialist, TB case manager, I've done many things. But currently, I work for Dr. Rum at the Department of Veterans Affairs in what we call our health, our home office, and I serve as his deputy director for policy. Okay, so moving right on into our discussion today, some environmental health concerns that veterans have mentioned can include Agent Orange, burn pits, chemical weapons, and I'm sure some of you are very familiar with those. And then some that you may not be as familiar with, or you may have, are Karshi Khanabad or K2, Karmad Ali, PFOS, and Camp Lejeune. So VA environmental health registries. So a registry evaluation is a free voluntary medical assessment for veterans who may have been exposed to certain environmental hazards during their military service. Evaluations alert veterans to possible long-term health problems that may be related to exposure to specific environmental hazards during their military service. The registry data may help VA understand and respond to these health problems more effectively and may be useful for research purposes. However, registries have actual and potential limitations that must be considered. So let's get into the strengths and weaknesses of these environmental health registries. You'll know this slide is a little busy, so I will point out one of our strengths of the registries. It can be a valuable tool for surveillance and epidemiology. It can be used for research, but we must recognize those limitations. And two of the limitations or weaknesses that I do want to point out for the sake of this lecture are recall bias and self-selection. We tend to see veterans who are sicker that tend to join the registries more often. So if you recall that I mentioned we had six registries. So we're going to get into talking about those registries right now. First registry I want to bring up is the Agent Orange Registry. It is by far our largest registry with over 700,000, 740,000 to be exact, participants within the registry. The eligibility for this registry includes if a veteran served in Vietnam, if a veteran also served in the Korean DMZ at certain times, as well as on certain Thai bases, and also veterans who served in certain occupational series, certain C-123 crew, and at a number of locations worldwide per DOD records. Also I want to point out that in 2020, Blue Water Navy veterans who served within 12 nautical miles of the coast of Vietnam are now eligible for the Agent Orange Registry as well. Moving on to the second registry, which is the Gulf War Registry, it's a little smaller than the Agent Orange Registry. And note that one-third of the participants in the registry, they actually deployed to the war. Veterans who are eligible for the Gulf War Registry are also eligible for the Airborne Hazards Registry, or what we call the Airborne Hazards Open Burn Pits Registry, which is our next registry coming up. So this is our newest and fastest growing registry, and it is the Airborne Hazards and Open Burn Pit Registry. There are about 300,000 participants in this registry, and like I said before, veterans who served during the Gulf War are also eligible to join the Airborne Hazards Registry. A recent IOM report released actually in 2017 suggested many ways to improve the registry going forward. Moving right along to our Ionizing Radiation Registry, which is our oldest registry. There are approximately 18,000 veterans enrolled in this registry. And keep in mind that this is also an older population because it is the oldest registry that we have. Next registry, our Toxic Embedded Fragments. So the Toxic Embedded Fragments Registry and Embedded Fragments Surveillance Center was created per one of the recommendations of the Returning Global War on Terror Heroes Presidential Task Force in 2007. About 16,000 veterans are enrolled into this registry. And you'll see I'm moving pretty quickly through the registries because we have a lot to discuss today. Next registry is the Depleted Uranium Registry, and it has about 6,000 veterans that are enrolled. Now we do have a cohort in which we follow, which consists of about 85 individuals who are invited to come to Baltimore every two years for an extensive evaluation, which takes about three days. Not all of the 84 may come to the actual center, but they are encouraged to attend. I also want to note that there are five positive DU isotopic signatures in those veterans who have an embedded fragment. So in five veterans that have an embedded fragment, they did test positive for a DU isotopic signature. Okay. And moving right along to ILR, which is our Individual Longitudinal Exposure Record, this is what we would consider the future is now here. We used to say that the future is coming, but actually it's here now. So ILR is a web-based application that provides the DOD and VA the ability to link an individual to exposures to improve the efficiency, effectiveness, and quality of health care. ILR will allow users the ability to create a longitudinal or historic record of service-related exposures per individual. So ILR matches a service member to a place, time, location, and event. And actually with ILR, we're trying to actually get our registries into ILR as well. And we're hoping that should be around, I think it's 2023. So moving on to what I do mostly, I am over what we call our environmental health clinicians and coordinators. These are the individuals that we rely on to do our exposure exams for us. So the structure of the Health Outcomes Military Exposures Registry Program. So we have 18 VISNs. And within those 18 VISNs, which are our Veterans Integrated Service Networks, we have what we call lead environmental health clinicians and coordinators. So within each VISN, we have one lead coordinator and one lead clinician. And then from there, you have approximately 127 VA MCs who also have clinicians and coordinators who actually see the veterans that have these exposure concerns. So it's approximately, give or take, 250 clinicians and coordinators at any one time. We could have way more than that as well. So and also, you'll know over here that clinics with our administrative responsibility, 60% of homes registry programs are administratively controlled by compensation and pension clinics. Okay. So our environmental health clinicians and coordinators, we have training for them, of course. So you'll see under War-Related Illness and Injury Study Center, the risk modules, we have five modules that we've just made it to where our clinicians and coordinators, it is a requirement for them to take the modules. So and also, those modules are available on train to community providers as well. And I'll provide that link for anyone who is interested in any particular module and if you would like to take one of those modules. Also, not only do we have those five risk modules for our clinicians and coordinators, we also have an annual conference. We do monthly presentations. We do webinars and efforts are underway for a possible certification program. So as I mentioned before, regarding our training modules, I would encourage you, if you're interested, to please, please, please check us out at the link provided. And also, there is also a directory of coordinators. And the reason I like to give this link out, just in case you have anyone who has a concern about military environmental exposure, you can always send them straight to this link. I am responsible for keeping everyone on that link updated. So this is a good way for, if you have anyone that needs any information, send them to that link so that they can get the information that they need. This concludes my presentation and now I would like to introduce to you my friend, my colleague and my wonderful supervisor, Dr. Peter Ruhm. I think it's going to be hard to follow Dr. Smith. Well, a little trivia question. I probably, or not, I'll give the answer up front. I'm probably the only pediatrician in the VA. I actually started out as a military pediatrician. I was at Fort McClellan, chief of pediatrics. I went down to Panama, where I became in charge of Fort Clayton Health Clinic, where my wife is from, and then took over a small hospital and also got Cuban refugees camps experience and other stuff and transferred over to preventive medicine. And it's been an interesting life. My life has taken me out of the military. I was the chief of the military in Europe. I was a state epidemiologist in Wisconsin. I've been at the FDA and now I'm at the VA. I've also been in academia. So one of these days I'll probably find a job I'll stick in. I like the one I'm doing a lot right now, particularly working with people like Dr. Smith and Dr. Katz and Dr. Robertson. And I just want to introduce, I'm going to have him raise his hand because I'm going to talk about him during one of my slides, I think. Dr. Drew Helmer was formerly part of our, you want to raise your hand? He was formerly director of one of our risks. And now he's in Houston doing even bigger things for the VA. And when I talk about golf or illness, I'll bring up some of his work, I believe. So anyway, it's not, and I will talk, one thing I want to mention is we did just get final approval. The certificate program, level one, is approved and online. And we're using the American College of Preventive Medicine to give a certificate for all, for physicians and others to get a certificate. And there'll be a level two. We're about six months to a year away of getting that, which will be more in-depth with case studies and readings and stuff to get a more advanced certificate. I think it would be particularly good for residents in occupational and environmental medicine to consider doing these trainings and get them. My title actually used to be called Director of Pre-911 because, before we changed over the way we do things in our office, and HOMS actually stands for Health Outcomes and Military Exposures. And the other thing that I want to mention is there's this huge endeavor going on, which Dr. Robertson will get into a little bit about. We're actually going to be starting to do about, during the pandemic, we did about 70% of our register exams were done by telemedicine and telehealth. And now we're actually opening what is called Vet Home out in Colorado, which will be a center with coordinators in-house, and then we'll have about 40 or 50 physicians around the nation to do real-time, not only registry exams, but also other environmental hazards exams and give advice. And so, for those of you, we'll actually be advertising those positions in the next few months. So anyway, I'm going to talk about primarily the two main exposures in Pre-911, Agent Orange and Gulf War. My particular interest is probably strongest in the Gulf War, because I'll talk about, I think it's a population that's still kind of underserved in what we do for our veterans. Vietnam, though, was a large war, and about 3.1 million veterans went over there. They served nobly. We had what's called the Blue Water Navy I'll talk about, another 250,000. It was an unpopular war, but they didn't lose it on the battlefield, and they fought valiantly. And one of the things they were exposed to was Agent Orange, which is, I'm not going to get into the chemical structure, which is the name I can't hardly pronounce, TCD and others, but the bottom line is TCD contained a dioxin contaminant. Agent Orange was named because of the orange barrel, but there was an Agent Blue, and Agent Purple, and so forth, and others. And all together, about 20 million gallons of these tactical herbicides were sprayed in Vietnam or in the surrounding countries. There was some limited use also in the DMZ. There's been testing in other places around the world where it's been used. And we have a website. It's called the Armed Forces Pest Management Surveillance Branch. It is a wonderful part of DOD, and they did a very intense investigation a few years ago and re-looked at where Agent Orange was used, tested, or stored. And they pretty much have confirmed that it was not used in Guam, Fort McClellan, where I was stationed, Panama, and some other places. Although a lot of veterans, there were maybe some commercial and other things that confused the issue. But we do get a lot of questions about that. The bottom line is... And then there was also a group that was not eligible for Agent Orange, what we call presumptions. I'll talk more about that. A presumption basically means you can get benefits in health care based on a rating from having a condition. If you're in the country and you get that condition, you're basically presumed to have been exposed. And so you get all veterans. We do know that the modeling of others, it necessarily wasn't a true fact across the board, but we just don't have really good evidence one way or another for a lot of cases. So that's one reason they get presumptions for a lot of that. And anyway, there was a court case and some battles, and finally the Navy got it as well, coverage for Blue Water. And I talk a little about presumptions. And we're changing the process. Our secretary is very immersed, and our office is deeply immersed in the process, along with the benefits people and others, in trying to improve the presumption process for veterans. I was the lead on nine rare respiratory cancers, which just became presumptions, from the Gulf War and the new Gulf War. And we just recently also put out presumptions for allergic bryonitis, and asthma for those same populations. And we're looking very vigorously about getting more veterans covered. There's a large bill called the PAC Act, which we're, in my policy role, I'm immersed with almost daily. There's about 15 bills in Congress right now. This is the one most likely to possibly pass. That would also open up other diseases to be possible presumptions. So we have a lot going on in this sphere right now. There currently are 17 Agent Orange presumptions. There's a couple that are not, that are being talked about. One is hypertension that's controversial. There was one paper that came out in the Chemical Corps, actually from our office, which shows some increased hypertension in the deployed population in the Army Chemical Corps. But the other evidence goes back and forth. And we are looking at possibly doing a presumption in that, the other one that's a little more involved right now is called monoclonal gaminopathy undetermined significance. And by the name, you know the condition. It's sort of a laboratory test, and most people do fine, but a few people go on and get multiple myeloma. Multiple myeloma is already a presumption, so we're still trying to decide what to do with that one as well. And the process historically to decide the evidence of these is primarily from the National Academies. We've had 11 Veterans and Agent Orange reports, and things change over time. For instance, Spina Bifida was in one of the previous slides, was considered to have limited evidence of an association, but then subsequent reports looked at that again and contested that and did not have that in more recent reports. But the bottom line is we finished, this is the last of these was in 2018. We don't expect to do another report because the population is old and aging, and pretty much all the studies have been done. One other condition that continues to come up is brain cancer. There's no evidence from the Agent Orange reports of brain cancer, but we are looking at that in other populations, particularly the Gulf War and more recent endeavors. So this just lists, this is a busy slide, just lists all these, and there are some like Porphyra cuticata are sort of pathognomonic, or chloracne, if you get that, you would, we pretty much know it's probably at least Agent Orange is a really good association. Others are not as strong, but we do look at them. This is just a slide, just one slide, and it's something that caused, I would say a policy issue because what happened was there was a single paper written by a VA investigator, but it was one of these journals you pay to publish, and they used some testing in Korea to look at 50 veterans for liver flukes, and they found some positives. The problem was we got the CDC and NIH involved, and other academia experts, Johns Hopkins and others, and they thought the test was basically not sufficient. In fact, the CDC argues against serology testing, and we're actually involved with the issues at Uniformed Services University on some study right now to look at doing more sophisticated testing, several types of more sophisticated testing for these flukes. But the bottom line, it caused a lot of concern, so we wrote a letter to the editor, but this comes up every once in a while, and again, until we get these further studies back, we won't know really one way or another, but it did cause in the Vietnam population, and again, some Vietnam veterans did eat raw fish, but not a lot, and so it's a small population, but what to do with those that did because the testing is not very good is a question. I'm going to shift gears to more recent. This is a war that I did not personally deploy into the war, but I went to Turkey and took care of some refugees, and I also was at Landstuhl Medical Center taking care of casualties during the Gulf War, and the Gulf War was a massive and successful endeavor with about 650,000, I believe, troops. There was this huge coalition of forces, British and others, French, others came in and helped, and it came in basically an air war, then followed by a short ground war, and we do know there were some Gulf War exposures, like any time you go to war, there are going to be these, but during the Gulf War, there was a thing called Kark paint, which was a chemical paint made to resist chemical agents, depleted uranium, most of that was friendly fire. There were concerns about solvents, fuels, and chemicals. We're actually looking at that more in depth right now with some more recent studies, and this thing at the bottom called Commissia, about 145,000 or so troops after the war were exposed to a plume of sarin gas when we blew up an Iraqi demolition pit, and in fact, going back to brain cancer, we're actually looking at that population, because one study did find brain cancer increased in the first 12 years after the war in that population, so it did not persist later, but we're looking at that more in depth with some additional studies. There were also pesticides, there was also the paracetamide bromide tablets taken to prevent complications in gas, and other anthrax vaccines. All these things are brought up to us, Dr. Helmer serves on what's called a Gulf War Research Advisory Committee on Gulf War Illness, and the bottom line, there's a lot of research still going on in this thing to try and figure out what is going on with the Gulf War veterans, and I talked about Commissia, again, there were about 100,000, it's actually more, 145,000 in the more recent data we have, and the brain cancer, and they've also found that there were some possible brain changes in some studies by Dr. Chow out on the west coast, and we're actually in the process of preparing a webinar to discuss this more in depth on a sarin hypothesis of paracetamide bromide as a possible thing of some of these Gulf War issues. But this is the thing that I want to spend the most time on, it's Gulf War Illness, and it's an enigmatic condition, affects about a third of the Desert Storm veterans, it also occurs in about 10% non-deployed. There's no definition, I'll get to that in a little while, but Dr. Helmer and another group have been doing some very advanced work on trying to help us make a case definition. One of those uses artificial intelligence, machine learning, and his used a very sophisticated chart review and some data sets, so we're, and there's no proven cause, there's not yet a specific biomarker, and there's no real ICD code, so this causes an issue for veterans trying to come in and get benefits. Right now in the Benefits Administration they use a term called undiagnosed illness, they do cover things like fibromyalgia, but veterans in particular are trying to get, would love us to come up with a definition, a better thing for what really Gulf War Illness is. It's also called chronic multi-symptom illness, which is a little broader term that fits in some things that Gulf War Illness doesn't get, but it basically has fatigue, pain, gastrointestinal respiratory symptoms, dermatological symptoms, and neurological symptoms. This was some research done by the CDC way back when, it had, again, 39% found cases, physical exam and lab tests did not help identify the cases, so again, you're kind of stuck with a symptom-based thing to come up with a condition. The Kansas, this is one of two definitions, one is called, they're used today, one is called the Kansas, Dr. Steele, who I met and interacted with, came up with, and others came up with the idea of having the six organ systems or symptoms that would lead to these domains, and that's, you have to have at least three of these to get called Gulf War Illness. And I talked about this, the GAO actually got involved with us, trying to help us, encourage us to get a definition, the National Academies put out a report where they honestly kind of, at the end of the day, just said to use either the CDC or the Kansas, and they couldn't come up with a definition. So we've been working on this for several years now to try and come up with a better definition. And I talked briefly, the VA one used predictive analytics and big data. The bottom line is, it's, and this work has actually been completed, Dr. Helmer's report is under review right now, and this one is being finished up, and we're going to try and get feedback in the next several weeks, that, and then we're going to try and sit down and figure out what's the next step of trying to get to a definition. And there are these presumptions, like in Agent Orange, there are Gulf War presumptions. There's chronic fatigue, fibromyalgia, but this one, as I talked about, this undiagnosed illness is the one that kind of fits the best to Gulf War Illness many times. But because, again, there's not ICD codes and not perfect symptoms, it's sometimes a little difficult. There are nine infectious diseases that also have presumptions. The actual burden of infectious diseases in the Gulf War was fairly low, but for those who did get one of these things, they can get coverage. I'm going to shift gears again to a policy issue. Methoquine is a drug used, DOD actually developed this at Rare. It was a successful anti-malarial drug, but it was known, it did have some psychiatric and depression-type findings and eventually got a black box warning from the FDA. But the bottom line, and it's significantly decreased, but it's still used by the Peace Corps and CDC and a few others, still recommended for certain populations, particularly pregnant women. Sometimes there's not another agent available, so it's still used. But the bottom line is there was a vocal group out there, including a former military physician who really claimed that methoquine was causing latent and long-term sustained neurotoxic or psychiatric effects. However, and I won't go through the literature here, but there's been a sniveling amount of literature in the last several years which kind of contradicts this. Except for the one at the bottom, the doctor I talked about before, Dr. Nevin, looked at some things and found some things. But other three papers have now from either CDC, the VA, or others. So these were reviewed by the National Academies, and they found insufficient evidence of association for methoquine. There was another drug called tefatoquine, which is a new anti-malarial drug, may cause a short-term ophthalmologic condition, but that's not thought to have permanent issues. And the last bullet says we have a study. We actually haven't completed this study. It has not been published yet, but it's been accepted for publication in Military Medicine. And we'll further add to the literature on what we know about methoquine. And then we're planning a second study. We just got access to the DOD pharmacological data, and we're going to be doing a very large study working with the Armed Forces Public Health Command, and we're going to be doing a study with them to look at methoquine toxicity in using military data. So now I'm going to go very quickly through some of the post-911 exposures, just talk about them. Depleted uranium has kind of been talked about. We'll go through the K2. We'll talk about PFAS, airborne hazards, and burn pits. We have in our office, we are so busy because we have everything, triclone ethylene, lead, EPA supervised sites are coming up all the time. And in particular, tomorrow morning I just heard there's going to be a very good talk on PFAS here I'm going to go to because that's a big area of interest in our office. Depleted uranium, the bomb line, this was used primarily in rounds, the United States rounds, so there was some friendly fire things, and as Dr. Smith talked about, there's only very low evidence of a burden right now. Only five veterans. They all had toxic embedded fragments, not toxic, to have some kind of elevated links. The other thing about this is that there was a recent, in the last couple of years, there's been a couple of really good papers that sort of ruled out depleted uranium as a cause for gulf water levels, or at least to point that way. So there's been a lot of work in this area in the last couple of years. K2, this is an interesting thing. This is a former Soviet base, and the bottom line is that we put troops there going in and out of Afghanistan. Some stayed there, some were permanent party, others went in and out, but did have jet fuels, depleted uranium, asbestos, volatile organic chemicals, and even concerns about chemical agents. Chip and the former command that I worked with did a study which found a small risk of malignant melanoma and neoplasm lymphatic and hemopoietic tissues. However, they didn't think the population was large enough to really prove that, and the confidence intervals were wide. So there's ongoing studies right now with this. The VA has a study, ASTDR has a study, and DOD has a study. They're all kind of working together on this, and our lead on this is Dr. Culpepper, if anybody has an interest in this. He's a real international and national expert now on this K2, and as I mentioned, this is an issue that comes up. We have a monthly meeting with the DOD, since a lot of you are from DOD in here, called the Deployment Health Working Group. We have leadership of VA and DOD get together, and then they go to a higher level interagency group to bring issues up. So things like K2 comes to us and goes up higher, PFAS comes up higher, we're frequently involved in these discussions and trying to come up with policy and so forth, and K2 has been on the agenda almost every other month in the past few, couple of years. PFAS is, of all the things we're dealing with, this is the one that could be the, I would say probably the next Agent Orange or as big, because it involves garrisons where bases, where troops are stationed and service people are stationed, and the, right now DOD has a study in firefighters, and we have a toxicologist, his name is Dr. Vincent, who's a senior toxicologist. She's on a White House steering committee, and they're planning other studies to look at this, and there's a call to create a registry. It would be an unbelievable thing to try and create a registry for PFAS, because there are so many of these bases and the population and so forth that actually do it, but there's legislative calls to do a thing in this. So we're, Dr. Vincent in particular spends a lot of time with these other federal agencies, and again, I'm looking forward to the talk tomorrow, more in depth on this topic. And then we have a, those of you in the military know, there were these things called burn pits in the Gulf War, in the more recent conflicts, where they burned these giant, almost everything got burned in these giant pits. But there also, you know, there also was particulate matter. There was smoke, dust, sand, everything else. And we have a center of excellence at the, I know she's going to talk about the risk in a minute. We have a center of excellence in New Jersey that deals with airborne hazards. But we have a fast-growing registry that deals with this, but we also have a lot, there's a lot of legislative activity looking at possible burn pits and covering them, both in the PACT Act I talked about, or in separate bills. John Stewart and Senator Rubio in particular are two people out there in the front of this issue, and there's a number of other people. We have another national CAJ report coming out on this soon to look at health hazards and so forth. We are, again, trying to get ahead of this by maybe creating some presumptions on things that make sort of biological sense, either very rare cancers or other respiratory conditions. I know we're going to be looking at, in particular, we'll be looking at respiratory cancers and others in the next several months to decide which way to go on potentially getting some more presumptions based on these exposures. And now I'm going to turn it over, you know, I'm very proud. I picked out, a lot of people I could have picked to speak at this seminar. The three I picked out here are world-class, and Dr. Michelle Robertson, she just really impressed me with taking on particularly telemedicine telehealth, and she's a member of your college, so I just want to say hello. Hello, hello, hello. Thank you, good job. Okay, so unlike the rest of my colleagues, I'm a bit vertically challenged, so I'm probably going to step out a bit. As Dr. Rao mentioned, I actually, I work at the World Related Illness and Injury Study Center, and I'm one of the occupational and environmental medicine doctors there. My background is actually in family medicine. I did family medicine for a long time, and worked with a wide variety of people and populations, including rural communities. And at one point in my career, when I was working in urgent care, I became concerned about the effects of workplace exposures on overall health. And that really led me down the path of occupational and environmental medicine. And then I found myself at the VA. It's funny. I got there, not on purpose, but I'm so happy I ended up there. I see a number of folks in the audience who are in service. Could you please raise your hands if you're in service? Please, no, thank you so much. We are particularly proud of the population that we serve, and we are just, we are indebted to you for all that you have done for us. So thank you so much for being here with us. We take this really seriously. In addition to that, my father was a Vietnam-era veteran and family of service. My brother was in the Guard, and I have cousins that were actually deployed to the Gulf. So when we do these evaluations, you're family to us. And so when we do this research and look at this information, it's really from the perspective of how can we help our family be better. So with that said, we're going to talk a bit. So Dr. Rahm spent quite a bit of time talking about a lot of the types of exposures that you hear about during deployments, especially combat deployments. But another exposure that comes up quite a bit are exposures that tend to occur in military installations, usually in the U.S., just during normal service and training, and these we call garrison exposures. You don't hear a lot about these, but this is probably one of the bigger areas of concerns for a lot of veterans that you may see either in private practice or if you're a VA provider. There are more than 800 U.S. military installations, covering over 24 million acres of this country, with a presence in every state as well as D.C. The total military acreage is greater than 20 of the current 50 U.S. states. That's a lot of land that military installations cover. And with that coverage comes the potential for a number of exposures that can occur during that time. As of 1992, according to the DOD, there was a survey that noted that more than 59 known U.S. military bases have been found to have been contaminated with some substance, either in the water, the soil, and even sometimes the air. But currently, VA does not have any registries for any of these garrison exposures. And just another note on magnitude, and you'll have to forgive me, my numbers are a bit off, but the purpose of this slide is really to kind of show that when you think about states that have the biggest burden in terms of acreage and exposure, the top states are California, New Mexico, Arizona, Nevada, North Carolina, and the beautiful state of Utah. So that is of particular concern. And in terms of the scope of military bases, the oldest military base was actually established in 1757, been around for a long time in Carlisle, Pennsylvania, with just a little bit over 400 acres, as opposed to Fort Bragg, which is the most populous base with over 238,000, and then Joint Base Lewis-McCard with the largest acreage, over 400,000. Now these last two I just mentioned because they come up quite a lot when we do our exposure evaluations, Fort McClellan in Anniston, Alabama, as well as Camp Lejeune in North Carolina. So first we're just gonna spend a minute talking about Fort McClellan in Anniston, Alabama. Now this was primarily a training center, infantry training, military police training, as well as some chemical corps training. And then the base was eventually closed in 1999 due to some exposure concerns. I did just put a note here about Agent Orange. When we see our veterans who are stationed there, oftentimes the question comes up about, well, what about Agent Orange? There are a number of other sites where Agent Orange was stored in or tested outside of that list of sites where we know it was used, Vietnam, Thailand, some of those places. So it is an important question that does come up. However, currently Fort McClellan is not known to have been one of them. Now Fort McClellan is really important because when you think about the contamination, it actually occurred from an off-site exposure. There was a chemical plant in the nearby town of Anniston called Monsanto that between 1929 and 1971 produced and released polychlorinated biphenyls, or PCBs, into the environment, which ended up polluting the water, the air, the soil. Now because of this pollution and the concern about health related to it, Monsanto eventually settled with the nearby community regarding health effects that could be related to that. But when studies were done to try to see what type of hazard would that have posed to the base, there really was not a lot of evidence to support a significant population level base of increased risk associated with these PCBs. Despite that, veterans continues to be concerned, and there have been calls for a registry, but at this point none exist. As opposed to Camp Lejeune, Camp Lejeune is a unique story in the history of VA, and I think it points toward a lot more of what we'll probably see moving forward in the future. In terms of history, from 1950 through the 80s, people living or working at Camp Lejeune in North Carolina were potentially exposed to water that was contaminated with industrial solvents and some other chemicals. And again, this primarily occurred from an off-site facility, some dry cleaning facilities that got into the waterways that fed this base. But when studies were done here to try to look at the health effects associated with those solvent exposures, there were a number of conditions that the literature pointed to, including these eight here that VA has now established a presumptive service connection for veterans, reservists, as well as National Guard members who were exposed, and these are the dates, and it is important because you have to have been there when the exposure occurred in order for it to be presumpted. But this is a first, where a garrison has been noted to have a presumptive service connected condition that is typically reserved for these deployment locations. This is the first time that we've seen this in a garrison exposure. And for us, it's terribly exciting because the exposures are the exposures, regardless of where they occur. And this is an example of how there have been movements forward to try to expand the reach and the care for the veterans who've served for us. So when you look at these conditions, the vast majority of these are cancers, right? With the exception of this last one, Parkinson's. Parkinson's disease comes up a lot, and it's actually one of the conditions that has been determined, considered to be a presumptive service connected condition with this particular garrison exposure. And this is for veterans, and it's important to note that this is for veterans who lived at the base, or military service member people who lived at the base. The second part of the issue with Camp Lejeune is for the first time, VA also has extended some coverage for family members, and that is a first. VA care is primarily exclusively for veterans, people who served. This particular program covers family members who also may have lived at the base during this time with their members. As we know, veterans and service members don't serve alone. Their families serve with them, whether they deploy or not. It's a family issue. In this instance, where there were family members who also lived at the base, VA decided to expand coverage to those members. Now, I'm not gonna go into the details, but just suffice it to say, VA still does not provide care to these family members, but the law does provide for VA to cover out-of-pocket expenses for certain conditions that are found in the literature to have been associated with solvent exposure. Now, you'll see this list is a bit longer than that presumptive list, and it's a bit different. This includes things like esophageal cancer as well as breast cancer, in addition to some other conditions that tend to be more time-related, including renal toxicity, female infertility, miscarriage, hepatic steatosis, as well as neurobehavioral effects. Now, these are the types of symptoms or conditions that tend to occur at the time of exposure. So, if you would expect these issues while a person was actually living at the base, it's not something that you would expect to see years later, but it is important to note that these conditions are on this list for family members. So, if family members live there, they do have the ability to apply for this program and to get some coverage for that. So, now, this is a plug. VA's worked really, really hard to try to find ways to assist healthcare providers in understanding exposures. Exposures, military exposures, environmental exposures, all kinds of, we live in a world of exposures, and it's often unclear how you manage that. What do you do with that? So, VA has completed this, has provided and made this VA Mobile Exposure Ed app, which any provider, you can download it on your phones now, I'm making a big plug, please do. If you care for patients and they're concerned about exposures, this is a great tool to use to help you have some information at your fingertips in terms of helping to talk with folks about these exposures, and it also gives some tips about communicating risks to folks as well. So, in terms of kind of just wrapping up everything we've talked about so far, military service is inherent with exposures to all kinds of substances, hazardous and otherwise, and a lot of these are environmental exposures as well as work exposures. Currently, garrison exposures, there is no registry for it, even with Camp Lejeune, although it has these tight presumptive service conditions tied to it, there's no registry associated with it. So that's important to understand. But I think the broader thing to recognize is that for any healthcare provider, when you're caring for someone in your office, the chances that they may have some military background or affiliation is huge. Either they served, their husband served, their cousin served, their mother served, their parents, so there is always a connection, and there's always a concern, and I think it would just behoove us to be aware of that, that this is far-reaching in terms of the population of people that we see in our centers. The last point I will say is, you know, we talked a lot about presumptive service-connected conditions, and really presumptions are one of those things where it makes it easier for a veteran when they submit a claim to not have to prove that the exposure caused the condition. VA will presume that if you were where we know this substance was, during the time we know it was used, VA will assume that you were exposed to it. And then if you get one of these conditions, VA will assume that you got that condition at least in part due to that exposure. That's where the presumptions are important. But if a veteran has a condition, even if it's not on this presumptive service-connected list, we always encourage our veterans to submit a claim if they think that their health issues are related to their military service. So, I'm gonna pivot. I know this is probably over halfway through our talk. We're gonna talk about telehealth. And telehealth is really important because what we knew at VA for a long time, and I think what the pandemic really helped the nation see, is the value and the power of being able to reach across and beyond the walls of a building to provide care, particularly for our veterans. We know our veterans come from all corners of this country. And so, after their service, they tend to go back to those corners of the countries. And some of those, they're not close to military facilities where they can receive care. So, it can be a bit of a burden for a veteran to try to get to a facility if they have a healthcare concern. Telehealth has helped us to get beyond that and to reach these veterans where they are. So now, a little bit about telehealth, even prior to COVID. VA recognized a long time ago that we needed to do something to be able to reach our veterans where they were. And so, even prior to the pandemic, VA had already dedicated a lot of money, time, and resources to creating this telehealth office about 10 years ago, and really was leading in telehealth innovation, trying to make sure that we ensured that veterans had some access to care, where they could connect with the VA healthcare team, wherever they are, wherever the circumstances, whenever it was convenient for them, and to really try to connect them with high-quality VA care. VA does provide high-quality care, and if you don't hear anything else, know that. When you look and compare the care that's delivered at our VA sites and compare it to any other healthcare system in the country, VA does a really good job. You don't hear enough about that, but they provide a really high-quality care. And so, to be able to connect a veteran to that care was extremely important. And there have been a number of successes. When we look at the numbers for fiscal year 2019, VA delivered more than two million telehealth encounters, which in and of itself is huge. That's a lot of people. As of fiscal year 2021, over nine million telehealth encounters had occurred, increased dramatically. This makes our hearts sing. That's more people that we can talk to, reach, and help. And when we think about the breakdown of those encounters, over a million of those were virtual mental health encounters. And we know that that's a very vulnerable area for our veterans, and we wanna make sure that if they need assistance in that area, that they can reach out for it. Veterans have been overwhelmingly positive with having this as an option, and they use it. Once they use it and get used to it, we're now at a place where it's almost an expectation. And again, I'm very excited about that, because the more they accept it, I think the more sites that'll be willing to put the energy into trying to grow that. Because I will say this, when you've been in a facility where the norm has always been, you must see a patient in person to deliver the best care. You gotta put hands on them in order to deliver the best care. When you're taught that way, it's sometimes hard to unring it. What this has shown us is, you can still deliver quality care, great care, without being able to touch the veterans. Seeing them, however, if you can do it visually, especially by video, and they can see you, the connection that you get is just as important and just as real. So there's been a lot of success in VA. I am gonna talk a bit about these environmental health clinics, because that's kind of where we live, in the environmental health clinics. And this is outside of primary care, per se. During the pandemic, a lot of these offices or these clinics, the staff that were detailed there, were really kind of moved, moved out to support other COVID-19 responses, as you can imagine. And so a lot of these clinics either shut down or stopped seeing patients in person, face-to-face. Now, of the ones that stayed open, though, about 75% of them went telehealth and used VA Video Connect, and I'm gonna talk about that in a minute. Now, as we were all deciding, well, how can we continue to reach our veterans and help them if they have exposure concerns, given the span of this country, and as Dr. Smith mentioned, when we talk about these visions and all of these centers, we needed some guidance. And HOME did a great job with kind of putting out some universal guidance for how we could successfully do telehealth, do telehealth encounters. And there were a number of criteria. And some of these, if you have a veteran or not, you know, you wanna make sure you get consent. They need to consent to be able to participate in a virtual evaluation. They need to understand what it is. And you need to make sure that it's a secure site that they're able to exchange in their information on. HIPAA compliance still exists. You still have to make sure that you're taking care of the privacy of the information that's being shared with you. So that was an important piece of making sure that we set this up right. But then you want to explain the purpose of the registry exam, and it's all there, I'm not gonna go through that. But in terms of how a successful telehealth program would go, really the decision was made was, if you're gonna do telehealth, at least for now, you wanna make sure that the patient has had a physical and has had some labs that's been documented in the VA healthcare medical record system. And typically, we'd like to see that done within 12 months. Now, we may go a little longer than that, depending on what else is going, 12 months, yeah, 12 months, that's right. And if there are no other new issues that have been voiced, then this might be a good person that you can do a telehealth encounter with, with the understanding that the veteran, one, does not have to do it. It's a choice. If they prefer to come in person, they can certainly do that. And so that's something that we had to take into consideration. And then once you do your evaluation, you just wanna make sure that you're documenting any consults, blood work, any labs that have been done prior to your visit with the veteran, and any recommendations that you may develop during that time. So in addition to making sure that you select the right patients, for telehealth, at least for us, although registries do not require that a veteran receive VA care or be enrolled in VA care, a veteran can only have a registry exam at a VA. Primary care provider can't do a registry exam. A civilian primary care provider can't do a registry exam. They do have to be done at VA. And for the purposes of telehealth, it made sense that for a registry telehealth eval, that they also already have an assigned PCP and be in the VA healthcare system with these other things noted. They have to be comfortable, of course, with telehealth, and you wanna make sure that they have access to the appropriate platform. And even from a clinic side, when you're selecting a provider, you know, not all providers are comfortable with telehealth. And they have to be trained, and you have to take courses, and you have to make sure that you're understanding how to best do those communications. And there are tons of courses that VA offers for providers to make sure that they're comfortable with that. And the duration of visit is also important. I know a lot of providers, you know, you're used to the 15 minute visits. Okay, that's not gonna work for an exposure evaluation. That's not gonna work for an exposure evaluation. And I'll give you an example of a patient encounter a little later. The typical duration of visits that we tend to have for our exposure evals, particularly for registry, can go anywhere from 30 minutes to two hours, depending on how many deployments they had, how long they've been in the military, how many exposures that they've had. In general, we usually think about an hour, understanding that it could be more or less. But certainly 15 minutes, I've not seen that. And if you have, please share with me how that worked. We would love to implement that into our program. And then again, even if you have a veteran that you're seeing via telehealth or video, if for whatever reason, the connection fails, and it will, you can't hear them, and you won't be able to, or you can't see them, you can always convert it to a telephonic evaluation and complete it that way. Now in terms of the platforms, at the beginning of the pandemic, you know, although VA had already had VB Video Connect in place, and that was really the preferred and the most frequent platform that was used, when we first started, you know, everything pivoted to telehealth. We had to find new ways for veterans to connect, because as you can imagine, the platform wasn't quite ready for everybody at that time. And so VA approved Cisco WebEx, as well as Microsoft Teams. Of course, these ones in the unapproved list, we never, you can't, you cannot, you can't use TikTok. Please don't use TikTok. You can't use Twitch, Facebook Live, any of those, and you still can't. But those were the approved platforms that were used at the time. In New Jersey, this was really a moment of growth for us, because although at our center, we had historically done exposure evaluations virtually, usually telephonically, but I had also started doing video, all of our registry exams had always been in person, had always been in person. We'd never done a registry exam, you know, virtually. So this was really an opportunity for us to change that. It was a lot of work on the front end, you know, because not only do you need the right provider, the right patient, you need a whole team to kind of put, you need admin support, data support. We had to create new clinics, make sure that the coding was tied to it. And this stop code, I put this here just in case you deliver care, you got to make sure that you code the visits right, because the last thing you want is for a veteran who's been promised free care with the registry exam to get a co-pay. That's a battle you don't want to fight. So you want to make sure on the front that you have your clinic set up appropriately. You want to make sure you designate the appropriate clinicians, the appointment days, times, and then we always review their medical records as well as their DD2 forms before we see them for the evaluation. So I'm not going to go through all of this, because that'd be another lecture. But this is an example of a presentation that I had made, a poster actually, that I had made and presented to AMSIS in 2020, the end of 2020, after we had stood up this approach for completing Agent Orange registry evaluations remotely. Suffice it to say, there were a lot of people involved, and it turned out to be one of the best things, I think, that we've been able to do for our veterans. So when we think about telehealth, there are a lot of pros, and I think we talked about them, right? It's convenient for the veteran. They don't have to drive an hour, two hours, fight for parking, wait two hours to be seen. Those are huge advantages that are not insignificant. And then also, this ability of VA service to cross state lines, that is a huge deal when you're able to do telehealth. And then for the veteran to have access with what essentially is a subject matter expert in exposures is also valuable for them. But there are some cons. We know that technical difficulties exist. There will be issues with internet. It will fall apart. And for the best experiences, I have seen that it's best to have two monitors, one where you can see the veteran and the other where you can document your encounter. And then just make note that not all veterans are comfortable with technology. Some of them are going to say thank you, no thank you. And that is completely fine. And we make sure that we try to accommodate them. We don't try, we do. We accommodate those veterans as well. And then the biggest thing, and I'm sure a lot of you are probably already familiar with this too, is the connection delay. When you're virtual, I swear, it always feels like you're cutting the veteran off or they're cutting you off. So I always apologize up front. I'm not. It's going to sound like it. Just remember to pause. So they hear you and you hear them. And you can have a successful encounter. OK, so now with all of that said, what I'd like to do for the next few slides is just kind of give you an example of the type of patient that we see and how we can conduct a full exposure history using telehealth. So this would be a telehealth evaluation that we have with the veteran. So I'm calling Mr. Doe to keep his information private. So this is an example. This is a 57-year-old African-American Army veteran who's referred to us for a burn pit in Gulf War registry exam. And what he really wanted to know was his breathing problems, shortness of breath, does this have anything to do with his military exposures? Does that sound familiar to anybody? You ever had that question, heard that question? Yeah, we get them all the time. This is our bread and butter. So this was a very typical evaluation. So now when we do our evaluations, in what we call a comprehensive way, we start from birth and we move forward. We take into account not only military exposures, but also civilian exposures. So for this gentleman, we start at the beginning. Turns out he was born at Camp Lejeune. Who knew? His dad was actually a Marine. And he was at the base with his family when this particular veteran was born. And he lived there for the first few years of his life, you know, before they moved on. And he actually decided to join the Army when he was 18 years old. And, you know, getting the rest of his history, he was a lifelong non-smoker. This was a gentleman who'd never smoked. From a military perspective, his MOS, or military specialty, if we get over at this point, of course, was as a wheeled vehicle mechanic. And we know that mechanics in general tend to have huge exposures to all different types of solvents, degreasers, fuels, oils, cleaning agents, all sorts of chemicals. And he was deployed to Iraq for about 18 months, which is a lifetime if you've been deployed, right? It's a lifetime. He was deployed for about 18 months, between 91 and 93. And his primary exposures that he was concerned about were exposures to burn pits, sand, dust, and oil well fires. And he was complaining about this progressive, you know, problems with his breathing. He'd started to have some coughing then, and it just seemed to get worse over time. And then after his deployment and returning to the US, he served a total of about 30 years in the military before he separated in 2010. But he continued to work as an automobile mechanic, and that's actually very common. They'll often continue to do the work that they were trained for. But this also means that he had some ongoing solvent exposure over the rest of his life. He had seen many doctors for his symptoms that he'd started to have, and he was eventually diagnosed with asthma. So now, most of the time you'd stop there, because that's a lot. That's a lot, right? Most of the time you'd stop there. But when we do these evaluations, we actually go a bit beyond just the exposures, just that part of the history. And so when we go back to the beginning, and we talk about, you know, well, what was your life like when you were a kid? You know, I know some of you are familiar with the term military brat, right? Well, he moved around a lot. Wherever his dad was reassigned or posted, he would move with his family there. And that was very difficult for him. He felt like he never really had a home. He never really had friends. He had a hard time connecting with people. It was just, it was a difficult kind of life for him, and especially when his dad would have to go away for training, and it would just be, you know, him and his mom and his sisters and brothers. That was a very stressful time for them as well. And then he also shared that his mother had been diagnosed, had recently been diagnosed with lung cancer. And so he's worried. You know, I kind of heard in the news something about Camp Lejeune, you know. Does this have anything to do with that? And if so, is that gonna, what's gonna happen to me? Do I need to be worried about this too? Plot thickens, no? And then when we talk more about his deployment, yes, he was a mechanic. But we know it's very common for our servicemen and women to be assigned duties outside of their military, for their MOS. So in addition to working as a mechanic, he was also assigned to man the burn pits, meaning the burn pits would burn. He was right there. He was the one responsible for throwing the trash in, the waste in, the military equipment, whatever needed to be burned, he was one of the people that was tasked with being there to make sure that happened. And then he also had the pleasure of being on latrine duty, I call it, latrine duty, where not only were they burning just trash, they were also responsible for burning human waste. Everything that had to get burned, somebody had to do it. He was one of them. And when he talked about his work as a mechanic, oftentimes they'd work outside in these sandstorms. Have you guys ever seen that movie, The Mummy? Ever seen it when the sand starts to roll in? That's what he said it looked like. And you get caught in that, you can't see. There's nowhere for you to go. You just gotta kinda hunker down and wait it out. So sometimes this would last a couple of minutes, sometimes he said it would last 20 minutes. He said one time he felt like it lasted 30 minutes, which is a long time, but that's how it felt, right? And then fast forward to his post-military, after his service, his symptoms got worse, he just was feeling horrible. And the combat that he had witnessed, the things that he felt when he was there, he carried it with him. And I think it'd be true to say that anybody who's ever deployed, you carry that with you. It's not like you go, you serve, you come back and leave it there. It becomes a part of you, what they saw, what they saw. So when he came back, he had all of this going on with him. He was really stressed out. He had a hard time reengaging in civilian life. He was just having a hard time with work. And when he would go to talk to his doctors, especially with his breathing, he was getting short of breath, he got really frustrated, because a lot of his doctors were saying, well, they didn't say it was all in his head, but that's what he heard. What he heard was, don't worry about it, take a deep breath, you'll be okay. Consequently, he started self-medicating, which we see a lot in regular civilian life. But he started using alcohol, drinking alcohol to try to deal with some of what he was feeling. And he was finally diagnosed with PTSD, which he'd had all along, but he'd never had a formal diagnosis for it. So all of this made for a difficult interaction between him and his providers, as you can imagine. So now when we finish our evaluation, we really kind of put together an assessment. I just highlight the biggest ones here, because we really do go by organ system. His first question was his asthma. Does my asthma have anything to do with my exposures? We had multiple airborne hazard exposures, as we just went over, for a long period of time. And as Dr. Rum mentioned, VA now recognizes asthma as a presumptive service-connected condition for those who served. So the answer for him was, yes, please submit a claim. And that for him was a huge deal, because as you can imagine, he was also worried about how he's gonna pay for all of this. How am I gonna pay for the care? I'm sick, I served, why won't they take care of me? That's the common question. And now he'll get some assistance with that. So for him, that was a huge weight off of his shoulders, that he could submit a claim for that. Now these other exposures, Camp Lejeune, right? Real exposure, real concern. So the first thing to tell them was, you're also eligible for Camp Lejeune. You lived there during that time. So you could also apply for this program, and your mother can too. And so she can get some assistance with her co-pays that have to do with her lung cancer. And in terms of any long-term health issues, our recommendation is that you continue to follow the same recommendations that anyone else would for this exposure. Because really, when we think about exposures, at least I do, I tend to think of it as a risk factor, like any other risk factor. It's an exposure may increase your risk of getting one of these conditions, like smoking, not exercising, all those things. So the recommendations for how you would screen for those conditions would be the same. So I really encouraged him to make sure that he found a doctor he trusted, and that might take three, four tries. Keep looking until you find one you trust, and then follow up with them and talk with them. And then, of course, his solvent exposure. Fortunately, he didn't have any significant health issues that seemed to be related to his solvent exposure, but we put a lot of emphasis in conversation about making sure that you protect yourself moving forward. We know you have asthma now. You don't wanna go in there breathing all sorts of chemicals that are gonna trigger some symptoms. So you wanna make sure that you're protecting your airway. You wanna make sure you're in a ventilated area, those sorts of things, so we talked about that. And then last but not least, his mental health. His mental health had to be addressed, because we all know that if your mental health is not in the right place, you're not gonna be able to do any of the rest of this. When people, I hate the term non-compliant. He's non-compliant. Well, he's not taking his medicine because he can't really get a hold on what he needs to do because his PTSD has not been adequately addressed. So there are always other underlying conditions, and so we added some support for that, and we always wanna make sure that our veterans have access to the crisis line, should they have any concerns outside of business areas. So when we put it all together, and we think about an evaluation like this, you know, they kind of break down into exposure concerns, medical concerns, and then how the veteran will engage in the healthcare system, whether it's civilian or VA. And there are a number of things that fall into each one of these boxes. But the most important thing to remember is that they all connect, right? These military service has inherent exposure concerns. When the veteran gets sick, they're gonna worry about that, and that will determine how they engage with their providers. So behoove us to be aware of that, to be prepared for that, so that we can support them. So with that said, I will turn it over to Dr. Katz, who will talk to you more about what we do at the risk. Dr. Katz? Yes. Thank you. Thank you. Thank you. Thank you. Thank you, Dr. Robertson. Great presentation. Thank you. Hello, everybody. I'm Ronit Katz, Colonel Katz, and it's truly a pleasure to be here. I know that some of our speakers spoke about their background. I was born and raised in Israel, was at Harvard, medical director at Stanford University Medical Center. When I found out how veterans are being treated in the United States, when the story of the Phoenix VA erupted in the news. I truly could not believe that veterans are being treated like that in our country. So what followed was I left my job, took a 45% pay cut, ended up working for the VA, and both my husband and I enrolled in the military. So thank you all who are serving. I do believe that freedom is not free, and sometimes, unfortunately, we are not being appreciated for what we do here as veterans. So I want you to know I have the highest respect for each one of you, the veterans, people that are coming from families of veterans, you know, years ago. It's really a special breed of people. So thank you. Let's give a round of applause to all of those veterans. Thank you. Thank you. Thank you. Thank you. And I need my glasses. Which pair? Thank you. All righty. All right, so that's who I am. I'm a colonel. I'm a state surgeon general for the California Guard, NASA Ames Health Unit consultant, clinical professor at Stanford University. I'm still a clinical professor at Stanford University, and I'm the director of the California Risk Post-Deployment Health Services and Clinics, and I'll describe what RISC stands for. So my presentation today will be about the RISC. RISC stands for War-Related Illness and Injury Study Center, and we'll talk about the RISC and the RISC model. The reason is my wonderful colleagues had spoken to you at length about exposures and about how many veterans are still suffering. Gulf War illness has been over 29 years since Gulf War, and still we have about one third of veterans that are suffering, and they have debilitating medical problems. So we need to help them, and I do believe that where I'm practicing now, the RISC is the best place to send them, and I will describe what it is and how to refer to us, and of course, we'll answer any questions. All right, the RISC basically is the War-Related Illness and Injury Study Center. Our focus is on post-deployment veterans and their commonly reported symptoms and conditions. Our mission is to improve the health, quality of life, and function of veterans with chronic and difficult-to-diagnose deployment-related health exposure and concerns. As you can see from the diagram, the RISC has three divisions. We have a research division, educational division, and clinical care division, and they're all interconnected, so we're all working with each other, and I'll discuss each one of them separately. I know I sound very arrogant, but I do believe that the RISC model is the perfect model for evaluating very complicated conditions like Gulf War illness and other unexplained condition, and the reason is we do personalized medicine, which nowhere until now you heard about it in the VA. There are currently, there are currently three RISCs with nationwide coverage. There is a RISC in New Jersey, RISC in Washington, D.C., and RISC in Palo Alto, the green. The RISC in Palo Alto is where I practice. As you can see, we cover practically the whole nation. The RISC in California is at least 11 states, and we are planning to expand, actually. What type of people do we see? What are our veterans' exposures, exposures concerns, right? They're all exposed, unfortunately, but what are their concerns? Either occupational exposures, like ionizing radiation, depleted uranium, environmental exposures, organic solvents, burn pit smoke, that's a big one because of the oil fire, hexavalent chromium, infectious agents, such as parasites, malaria, and other infectious agents. In fact, even liver fluke, and Peter, I had one patient that I referred to the CDC. We have patients with unexplained conditions, what we call Gulf War illness, and patients with constrictive bronchiolitis. Other group of patients is when they suspect that they have an adverse reaction to prophylaxis. For instance, persistent mefloquine toxicity, or reaction to the PB pills, the PB tablets, as many of you know, are antinerve agents, and there is a school of thought that say that maybe this is one of the causes for Gulf War illness. So they come in, they read up on the internet, and they say, I was exposed to this, I took it, and this is why I have Gulf War illness. Or reaction to the vaccines. Unfortunately, from what I heard from them, when they were deployed, it wasn't the usual way that we give vaccines. Okay, wait six months, come back in three weeks. They were deployed, and they were given multiple vaccinations at once, and some of them are concerned about the possibility of having multiple vaccinations at once, and the burden on the immune system. Okay, our referral process. Who is being referred to us? The people that are being referred to us are people with medically unexplained symptoms. Those are problems or illnesses without a known etiology. Veterans who had extensive workup and treatment without improvement do not get better. Possible deployment-related environmental exposures, and again, many times we have no way to verify. There are certain groups, like the groups at the Khamisiyah that Dr. Helmer and Dr. Rahm were talking about, that they got the letter from DOD, and we know what they were exposed to, but it was such a chaotic war that sometimes we just go by what they say. I was in this region, so we assume they were exposed to A, B, and C. They come to us also when second opinion is not available locally, right? We've got a big country, and quite a common scenario is when providers are frustrated with the lack of patient progress, because unfortunately, these poor veterans, and I don't mean monetarily, they run around from one doctor to another, and they are asking for answers, and because we don't know what the illness is, we don't have any answers for them, and that could be extremely, extremely frustrating to a veteran. Remember, there's people who are willing to give their life for our country, and for us to say it's in your head, or for us to say we can't see anything, or man up, women up, it's very frustrating to them, and unfortunately, I have seen it here, and when they come to the risk, the experience is completely different. Let's talk about the referral process, since hopefully you guys are going to be the referring providers, whether you are part of the CHOICE program or the VA. By the way, is there anybody here who is a VA provider? Perfect. Excellent. And non-VA providers who would be working with veterans, part of the CHOICE, outstanding. So I'm talking to all of you, okay? So the referral process is very simple. Who makes the referral, anybody in the VA? In a nutshell, typically it would be the VA primary care provider, okay? It can be the patient allied care team, what we call PAC team. It can be the post-deployment health champion, or even the environmental health provider. How do you do that? Simple. You enter IFC, IFC stands for inter-facility consult, into CPRS, CPRS is basically the electronic medical record in the VA, for those of you that are not familiar with the VA system. And in the consult, you write that you want consult to be referred to the RISC, War Related Illness and Injury Study Center. What happens once you enter the consult, the referrals are automatically triaged to the regional RISC based on the location of the patient, okay? So for instance, if I'm in California and I get an IFC consult in California, I should be assuming that the person is either from California or the neighboring states, right? Very, very rarely we see some consults from other RISCs, but they are just like onesies and twosies. But in general, think regional. As we mentioned, the RISC has three divisions, right? Clinical research and education, and I'll talk on each one. The RISC clinical services, we have a multidisciplinary team approach to address the complex symptoms that are related to deployment. Once you send the consult, each one of us on the team review the IFC, the inter-facility consult, review the patient records, review the notes from the doctors, and come up with some recommendations. And then every Wednesday, we meet as a multidisciplinary team where each one of us presents our point of view as to how we can help this patient and what would be the disposition of this consult. Some cases will be an e-consult. What an e-consult is, we have done the thorough medical review, medical record review. We recommended some diagnostic impressions, and then we sent basically tailored recommendations to the home VA. So the workup will be done by the doctor in the VA with the patient, okay? And again, they can always contact us for further if they need, but this way the veteran does not need to travel, and we give the doctors some preliminary work to help the veteran. The second tier that we have is what we call comprehensive multidisciplinary evaluation. This is personalized medicine at its best. We fly the patients free of cost all the way to California, beautiful California, right? They come for a week, and throughout the week, they meet with our multidisciplinary team. And they are there literally every hour and a half seeing a different provider. Don't think they're touring California, okay? And each one of us provide recommendations. The last day of the visit, they actually get a tailored recommendation, an impression as to what we believe is going on that we discuss with the veteran, and also we send all of those recommendations to the patient doctor. So when they get home, basically they get a roadmap of tailored recommendation to improve their function and quality of life. And remember quality of life, it does not mean that we are, we solved the illnesses that they have, but anything that we recommend would make their life easier. And of course, we do enhanced airborne hazard evaluation, exposure, exposure, exposures, and they're quite happy when they go home. The third one is the more simple evaluation, we call it the TEC. The TEC is when somebody has one, five minutes, okay, I got to rush. So the third one is going to be a very, very quick one, only exposure, let's say somebody was exposed to Agent Orange, our nurse or nurse practitioner will call them and say, you were exposed to Agent Orange, those might be your symptoms, those are the illnesses that you need to pay attention to, this is the surveillance that you need, and that's it. And of course, if they have questions, they contact us again. And I'll move with your permission a little bit faster. All right, let's talk about the on-site multidisciplinary evaluation. What does it consist of? We've got internal medicine and neurological exam, this is the on-site people that come on-site. We've got psychological evaluation, neuropsychological evaluation, advanced testing, every person that comes to the California risk, unless there is a contraindication, will end up with a brain MRI. We do a very thorough environmental exposure. I'm board certified in occupational environmental medicine, I'm the one who evaluated them. They give me an hour, it usually takes three hours, because I ask about exposure from birth to the moment that they meet me, okay? Work related, not work related, childhood, secondhand smoke, et cetera. We have an education second, complementary and integrative medicine session, yoga even. We have spiritual assessment, social work assessment, nutritional evaluation, and education. And I'm happy to tell you that after this, we call them three months later and six months later to see if there was any progress, if there's any improvement, and if the doctors and their healthcare provider followed up on our recommendation, which they're extremely happy about. And, in fact, we just started doing even whole health coaching. That's the buzzword in the VA now. All right, the research part. The goal for research, the risk has a very particular focus on goal for research, because as we mentioned, has been over 29 years since Operation Desert Shield, Desert Storm, and they're still suffering. The goal in the research is to understand the underlying symptoms as well as develop and of course test those treatments, particularly treatments that are focused on symptoms specific for the veteran. Okay, so if you want to learn one thing from all of it, symptoms specific treatment for that illness. And we've got quite a few research going on. Some of the research was discussed before. We have a yoga and goal for illness research. We've got transdental meditation for veterans. This is something that's being started right now, alleviates PTSD and hypertension. We've got TMS, which is Temporomandibular Stimulation for Depression and PTSD, quite helpful. And as Dr. Ramm mentioned, we at the California RISC are looking into becoming a center for brain health, center for excellence in brain health, and to see if there are any possibilities, I'm very careful with my words, that there were some exposures that increased the risk for brain cancer. Okay? And we just had a meeting about it, I'm on the committee as well. So what are our goals and what are our dreams? Okay? Because the model is so successful and we have so many patients that are giving us kudos, but one very complaint is, I went there once, everything was great, and the rest, I'm going back to the VA. I need to see you guys again. And it's impossible that few of us would see everybody else, right? So we came up with what we call stepped care model, and thank you Dr. Helmer for being part of it, where it's like a hub and spoke model. We will have satellite clinics in each VA, and then throughout the nation, there will be local experts. And of course, if they have questions, the questions will come to us. How do we make this dream a reality by education? So the education division, and my colleagues already spoke about it. We do in-person conferences. We do train the trainer activities. We continue to provide veterans and veterans group educational activities. We partner with environmental health clinician in each facility. We train our provider at any level about exposures. And one group that is extremely important that we are targeting now is, some of you in the room, the choice physicians. And we try to partner and market PDHS risk services to them. And the reason is, as you know, veterans can go now to a known VA provider, which many of them are outstanding. The question is, if you go see somebody, let's say for Agent Orange, but the physician is not familiar with Agent Orange, presumptive or illnesses, right? You're seeing him for cardiovascular disease, he will treat the cardiovascular disease, but will not continue surveillance for conditions that might be sequela of exposure to Agent Orange. This is why we are very, very strongly recommending that non-VA providers will take our modules and learn about it. Now, I'll be very quick. If you want to learn more about it, we've got a lot of e-learning accredited education. They're practically free. We do provide education in person, online, webinars, TMS, e-learning modules, Education of National Societies, ACOM, ACPM. And my conclusion. Thank you. This concludes my presentations. I would like to thank our listeners, my colleagues, ACOM, and most importantly, the veterans. Your dedication and sacrifice in serving our country is deeply appreciated. Thank you. If you have any questions, Dr. Peter Rahm will address them. Over. We actually went a little long, and I'm sorry about that, but we covered a lot of content. We'll take a few questions. Go ahead, please. Yes, ma'am. Yes. I actually work at the VA, so I really appreciate this, because I actually started doing these exams, so this is very informative. Thank you so much. I was kind of curious if you actually have physical level data in terms of how many of these are involved, and especially the birth rates. I feel like there's a lot of data, but I'm just curious if you actually have physical level data in terms of how many of these are involved, and especially the birth rates. I feel like there's a lot of data, but I'm just curious if you actually have physical level data in terms of how many of these are involved, and especially the birth rates. I feel like there's a lot of data, but I'm just curious if you actually have physical level data in terms of how many of these are involved, and especially the birth rates. I feel like there's a lot of data, but I'm just curious if you actually have physical level data in terms of how many of these are involved, and especially the birth rates. I feel like there's a lot of data, but I'm just curious if you actually have physical level data in terms of how many of these are involved, and especially the birth rates. I feel like there's a lot of data, but I'm just curious if you actually have physical level data in terms of how many of these are involved, and especially the birth rates. I feel like there's a lot of data, but I'm just curious if you actually have physical level data in terms of how many of these are involved, and especially the birth rates. I feel like there's a lot of data, but I'm just curious if you actually have physical level data in terms of how many of these are involved, and especially the birth rates. I feel like there's a lot of data, but I'm just curious if you actually have physical level data in terms of how many of these are involved, and especially the birth rates. I feel like there's a lot of data, but I'm just curious if you actually have physical level data in terms of how many of these are involved, and especially the birth rates. I feel like there's a lot of data, but I'm just curious if you actually have physical level data in terms of how many of these are involved, and especially the birth rates. I feel like there's a lot of data, but I'm just curious if you actually have physical level data in terms of how many of these are involved, and especially the birth rates. And that has now under other leadership, he's moved over to Houston doing some other research, but the bottom line is there's a lot of research being done, both in the registry, where they're going to try and get data back to the providers, so you get some results of what your exams are showing. We're really working hard on that. And I probably, if you wanted to come up and meet Dr. Smith, she's probably your best contact to get, to know and get information out, because we have, you should be coming, you should be on the calls, you should be on the webinars, and there's a lot of things you can get. But the airborne hazards is looking at getting better data. They have an advantage, they switch to a different system than the older registries. They can actually get better data, and now they're trying to tap into that. So there's a, that's a very pertinent question, and it probably will have, I would say it's probably three months away from getting some really good reports out. That's the best I can say on that. Anybody else have a question? This man right here, and then we'll go to the man in the back. All right. Are there any upcoming overhauls or changes on a larger scale regarding compensation and pension program to create more efficiency, there's more data driven, statistics based? I have a feeling that... Yeah, I alluded to that. I'm going to go very quick. I alluded to that. We are, compensation and pension has kind of been outsourced and insourced, and it comes under benefits as well as, it kind of crosses both VHA and benefits. We don't really work in that field, but there is a, if you're touching on whether to get more benefits for veterans through presumptions, there's a vigorous effort going on to try and get more diseases covered. Part of that process I just talked about, I personally wrote, we got nine rare respiratory cancers approved for presumptions for the Gulf War and the post-911 wars, and I was part of a process of writing the training manuals for the compensation and pension physicians on those cancers. So, we actually had to do a lot of research to get data to them to get it. So, there's an innovative, if you want to come up here, I'll give you my email, and I'd like to get in touch with you to give you more information as it comes along. And we had a man in the back, right back, and then the lady. The work you're doing is fantastic, and it sounds like it's a great improvement over perhaps what the VA has been in the past. I have a vacation position with people who are against, unrelated to the VA, but I do ask about their military exposure and the like. And time and time again, I hear, I'm in the VA system, I've seen the VA doctor, and he never asked about the burden. He never asked about my, even sometimes never asked about their exposure. That's a fair point. There's one thing, there's a fair point there, and it's very, we're trying to educate. The secretary has made it mandatory, all physicians in the VA have to do, all primary care and other specialties have to do an hour, it's actually 90 minutes of military exposure training this year. My question is, I refer them to the VA doctor to get them in the verge of registry and so on, and they hit the brick wall. So there's no way I can make the referral directly apparently, or is there? I'd like to give you my name so I can get that complaint to the right person. We're trying to do a lot on that in many spheres. The other thing is, in the VA system, we're also working hard on a clinical reminder system for both the current CPRS and the new Cerner, where every person comes in and they'll get asked a question about military exposures, and the provider will have to get that information. So that's another step we're taking on right now. There's a Dr. Stephen Hunt out in Seattle, who Dr. Helmer knows too, who's kind of along with some other people leading this. But I'll give you my, anybody can email me anytime these questions. My email is peter.rumm at va.gov, and we'll try and get you an answer. And then there was a lady who was asking a question in the back. Come up and talk to me afterward. It depends on your situation. If you want to stay in the Philippines, or whether you want to go to Hawaii or somewhere, there may be some possibilities. The VA is hiring physicians a lot. This thing I talked about, Vet Home, is going to hire 40 physicians to do telemedicine in the next few months. So there will be physicians. And the bottom line is that the care in the VA has been improving and will continue to improve. Thank you so much. Thank you, everybody. Thank you. You've been a great audience. Thank you. Thank you all. Can I tell you guys, I go to the polls like every couple weeks, but it's just nice to physically see you. Yes. Oh, good. It's so important for me to physically see you guys. Like, this is so key. I was so excited for this talk today. I'm like, I get to see you guys. Oh, you'll be here for that. Yes. So email me. You obviously know this. Yeah, I'm going to email you. I know. Put a face to a name. No, we want to help you. I know. I'm telling you. We want to get it out there. You can email me. All the time. And I'll always get back to you very quick. No problem. You have done a lot in this college. Boy, past president, we've got to help you. Bill Greaves was a past president. He's a friend of mine. Bill and I were very close. I was in Wisconsin together. Peter. Hello. Hi. I'm sorry. Do you know where the skin is? Yeah. No. That's great. Sorry. You're at Tacoma, Washington? Yeah. Peter.rumm.va.gov. R-U-M-M. R-U-M-M. R-U-M-M. R-U-M-M. R-U-M-M. R-U-M-M. R-U-M-M. R-U-M-M. R-U-M-M. R-U-M-M. R-U-M-M. R-U-M-M. R-U-M-M. Peter.rumm.va.gov. Yes. r-u-m-m. r-u-m-m. r-u-m-m. r-u-m-m. r-u-m-m. r-u-m-m. r-u-m-m.

telehealth

VA registries

Agent Orange

Gulf War illness

burn pits

environmental medicine

occupational medicine

VA environmental health registries

VA Mobile Exposure Ed app

War-Related Illness and Injury Study Center

post-deployment veterans

compensation and pension program

chronic health issues