We're very, very pleased that you're here with us today. My name's Steve Hunt. I'm a OEM doc out in Seattle. I work with the VA here at the University of Washington, a clinical professor there. My main work right now that I'll be talking about later is the toxic exposure screening that we're doing for all veterans in the VA. And Michael and Joe will introduce themselves as well. Why are we doing this? I'm recent to OCMED, actually. This is my first ACOM conference in a long, long time. And I've been so struck by the many ways that this profession is put to use in different populations to promote aspects of health care that are everywhere. But in many ways, as a profession, I think sometimes we don't appreciate the breadth and depth of what we have to offer. I've worked with Joe and Michael, both at the VA when he was there as chief of employee health. What was your official position? Yeah. OK, before OSHA. And then Joe, who was head of OCMED at Walter Reed when he was active duty, retired colonel. So we just wanted to share with you our own personal kind of trajectories of getting into this specialty and what we've done with it and why. And really, what we're talking about is not just the three of us and the sorts of things that we've been doing with our training, but each of you. I mean, I've spoken with a dozen people here. And each one has had a very interesting trajectory in how they ended up doing OCMED, what they're doing with it, and really, how can we expand the relevance of what we do to health care in a broader way. So each of us are going to just spend a little bit of time talking about how we ended up doing what we're doing and kind of the meaning that it's had for us. And then we'll talk just a little bit about the field in general and ways, maybe, in which we can, like I say, broaden the relevance of occupational environmental medicine in health care in general in the US. So Michael is going to start and talk with us a little bit about his journey into and through occupational environmental medicine. Oh, yes. OK. So I was working in the VA for 15 years. And suddenly, I realized, you know, I'm doing occupational environmental medicine. I'm taking care of all these folks that have been doing these jobs that have every health risk associated with them that you can imagine with all these health consequences. And they've been doing these jobs in environments, whether it's garrison or deployment or combat, that have every risk imaginable that can have negative impacts on health. And I just called up Joel Kaufman at the University of Washington, Achmed, and I said, hey, you know, I've been to VA for a long time. I think I'm doing occupational environmental medicine. Maybe I should get some training. And he said, come on over. So I did my MPH in Achmed training and have been then. It's helped me immensely in kind of refining the way that I approach care for veterans. So that's why we had the first slide, which essentially, you know, oh, just a disclaimer for all of us. So in certain ways, for me, really, occupational environmental medicine is the foundation of both veterans health care and military health care in many respects. And we've all kind of touched on Achmed in those settings. And so that was just kind of the first thought for me that brought the three of us together. I have to add, too, that I revere Dr. Hodgson, Michael, and Joe as well. And to have had the privilege of working with them and learning from them has been a really remarkable thing. So that's another reason I'm very happy to be joining them up here today. So Michael's going to start telling us a little bit about his work. And I'm still not quite sure what Steve and Joe wanted out of this session. But they said we should have a bio slide, and then we should lay out some of the conflicts that we think are important. And I then have some examples. So some people know, although I was born in Switzerland, I went to medical school in Germany, started out in surgery and occupational medicine, came to the US, did internal medicine. The CDC was an academic for years, back to CDC. And then from 99 to 2013 was the chief consultant for occupational health for the VHA. Those years, people don't necessarily recognize the current VA in the same way that the VA in those years, which invented patient safety, the electronic medical record, quality management. I mean, all of those, it was innovation central in health care. And then in 2013, after I'd been forcibly removed for doing something that I thought was necessary, but it was probably a stupid thing, a job I had applied for three times before not gotten opened up and went to OSHA. So when I applied for it the first time in 1990, when I was still a medical consultant for the steel workers in Pittsburgh, and we would then call OSHA only when there was a failure, when we couldn't negotiate something. So in those years, I thought OSHA is an ineffective organization. It's there as a flag. It sets these basic standards. But most of the things that we do in health and safety in the US go way beyond OSHA standards. I mean, people have looked at the lead standard. People, I mean, it's just, it's the respirator standard. Do you have to have an eye or spirometry technician course to? So those kinds of things. But I've wanted to do OSHA, and I thought the reason was that in 1984, when one of the bridge workers, one of the iron workers in Pittsburgh wound up with a level of 134 seizing on a bridge, turned out the doctor who was managing that was treating these people with EDTA. So we wrote a letter to the Office of Occupational Medicine, Ralph Yudakin, and said, this is a problem. You should do something about bad occupational medical practice. So OSHA wrote a letter to Allegheny County Medical Society, and the Allegheny County Medical Society wrote a letter back to Ralph Yudakin that did copy us with this. And it said, thank you, we'll handle it our way. And he continued to treat them with EDTA, because OSHA has no, you know, it had relatively little power over doctors. So what is OSHA? There's the Directorate of Standards and Guidance that sets standards. It does, you know, complex regulatory stuff, and some of you know that it took, I mean, the last big standard was silica, and that took 20 years to implement. It's not really fast. Higher violence, well, the infectious disease standard draft came out in 2011, when I was still at the VA. We wrote lots of stuff back. It's still not out. The violence standard has been around at least that long. OSHA is a very constrained organization, because the primary role of government is due process, so that everybody gets heard and has the right to influence the politics that we live with. So DSG provides set standards, and then provides some unenforceable guidance. The agency has these 10 regions, about 90 area offices with field staff. It's a law enforcement agency. I had to turn in my badge, because I retired two weeks ago. So it's a lot of fun to run around as a compliance officer and say, no, you cannot make me leave, because back in the early 80s, NIOSH would still use a warrant to get into employers. We're out in Hot Springs one day after negotiating with Union Carbide for a year, drove out to Hot Springs, Arkansas, with an 18-wheeler, the whole crew, field crew, to do, you know, three lines of spirometry, portable x-rays, in a vanadium or uranium plant. And the night before, Union Carbide shut down the plant, and when we knocked on the door in the morning, they said, oh, sorry, we shut down last night. And there was, you know, that kind of stuff happened. NIOSH doesn't do even that anymore, because John Howard is trying hard to maintain funding for academics. So these institutions, OSHA, NIOSH, they are organizations that have a set of agency priorities and rules of procedure, and they often differ dramatically from what we as clinicians think is appropriate. And in fact, not infrequently, the rules that the agency pursue put us in conflict with ethics. I'll talk about three examples in a minute, but the reasons for that are that there are fact constraints, there is administrative law that gets in the way. But we think of fidelity, truth-telling, and beneficence as primary ethical principles As occupational physicians, all of you have heard the dual master problem. Who do we owe that to? Our code of ethics says we owe it to the patients. But as a physician at OSHA, I don't have patients. I work with the agency, and when I review medical records or interview workers who have been injured or get the autopsy from deaths, I don't really have a formal doctor-patient relationship with any of those people. And so in the same way that I get pretty upset about this, you know, our compliance officers who run around get pretty upset about things because many of them have families at home and kids, and when, you know, somebody shows up at a farm worker plant where a bunch of people blew up a tire, you know, one of these big agricultural tires because they forgot to put a regulator on the valve, and two sons got blown into the side of a truck, both of them dead, one of them brains spread out cleanly on the field in front of that truck. It's a painful thing to look at. And so trauma in the compliance officers is actually a pretty common problem. And then we see the issue of what the phrase that the VA coined of moral injury has a common problem. So, for example, the work that I do is covered under the Privacy Act, and the agency does not release that until we've issued a citation. Even then, it can only be obtained through a Freedom of Information Act. People who were in my talk yesterday about Daikin America, two clusters of deaths a year and a half apart that got settled two years later, the widow with her three kids was still waiting for the workers' comp settlement, and her lawyer wasn't, you know, didn't quite get what they had. So you wind up with conflicts in federal agencies that can pose very serious ethical problems. And for many of us, we need to think carefully, how do we manage those? And as adults, we all encounter things where there's, you know, a line that we cross or don't cross, where we try and figure out, what can one do? So just three examples of these kinds of problems. And residents are around who had worked on each of these three here this year, a 35-year-old construction worker insulating kind of the top floor of an ice building, ice cream maker, nationally recognized ice cream maker that had an ammonia-based refrigerating process. They had crawled up under the dropped ceiling to insulate it. One morning, he crawled up there, and there was a ton of ammonia up there. And it turned out that the exhaust had stopped working, everybody left, the foreman made them go back in, he wound up in this attic for an hour, and wound up then getting taken to the ED, had a seizure. So if you look through the literature on ammonia, you'll find two reports over the last 60 years of seizures from ammonia exposure. But if you explore the pediatric literature, it turns out there are metabolic pathways, rare, but metabolic pathways, where you get preferential ammonia, you know, inability to metabolize, and therefore, it is feasible that people would in fact wind up with ammonia, we know that from hepatic encephalopathy, that would lead to seizures. So Children's National Medical Center gave us all the names and the ways to get that enzyme, and the local physician wouldn't draw blood to send that off to California to be able to document that this person had a biological reason for a seizure. I don't know that that was the reason, I don't know whether the seizure was in fact work-related, although I can't imagine it wasn't. We issued our citation, a man developed bronchiectasis. Once the case is gone, once we've issued our citation, I don't have any follow-up. So as a physician, as an internist with, you know, now close to 50 years, this is a painful thing to watch. I presented those two death clusters yesterday. The OSHA reports were not available to the family that was pursuing the worker's comp claim. The first case that I talked about was a bunch of contractors. So Dike in America would have been, you know, susceptible to a third-party lawsuit. And people who remember the 80s will remember that the asbestos problem in this country was solved not by OSHA or EPA asbestos standards, but by the litigation that forced the asbestos companies to change some behaviors. So third-party litigation remains a very powerful thing. In this case, Dike and settled the first cases very quickly, although it took another two years for them to agree on the abatement. So they dragged out into a long period of time exactly what they were going to do, and in that time killed another few people. So as a physician sitting at OSHA, I see this makes me a little angry, but there's not really anything I could do. And if, in fact, I gave out my report, our lawyers would be pretty unhappy because they control the litigation and negotiations process with the employer. Eventually wound up with $175,000 and $100,000 fine for those two, which for OSHA is huge. But it didn't do the people any good. And the third case, one of the Hopkins residents worked with me on three undocumented workers who were working out in Kansas cleaning a truck of work next to a pork processing plant. And the tanker truck would drive over to the pork plant, fill that tanker back with the leftovers that didn't get turned into meat, drive that off to a dog food plant, and then come back, and these workers would then use hoses to clean the inside of that tanker truck. You all know that's confined space. You all know that pig innards are likely to produce H2S. Somebody who doesn't know what that does may not know that. Turns out the first guy went in, keeled over. We don't know why that one day things were different than another day. One person went in, collapsed, a second person went in, tried to get him out, collapsed. The third person went in, noticed something was going on, climbed out. They called the EMTs. They actually extricated. Two of them died. One of them has long-term CNS damage. Because they're all undocumented immigrants, they get no worker's comp, obviously, because they'd have to be identifiable. The two dead, the two decedents were transported back to Mexico at the cost of the family. And so you see this as a federal employee, and you realize there's nothing you can do. There's just nothing you can do. Thank you, Michael. Now, I'm not going to talk as much about kind of moral conflicts or kind of clinical conflicts like Michael did. My name is Joe Ortiz. I am currently the Associate Director of the Complex Exposure Threat Center, which falls under the War-Related Illness and Injury Study Center in the DC VA. But much of what I'm going to talk about is more of the challenges of what I did in my career in the military as an occupant physician, and then transition to the VA. I think it was interesting that Michael talked about who do you serve as an occupant physician. And what I always tell my residents is it's really kind of 51%, typically, as a military physician, I really served who I worked for, which was the military. But I still felt there was a 49% that I really served the service member or the employee, because you still have to do your best to keep them ready to serve in the military or whatever they do as an employee. So the other thing I want to do is talk a little bit about, whoops, there you go, you know, kind of my, give you some advice about, you know, my career and kind of what helped me throughout my career. And kind of the big things that I would advise is, number one, you know, build a portfolio and experience. I think the military is really good, you know, because we have to move to jobs every three years, you do a lot of diverse things, and you'll see in my career, it's pretty diverse. And part of that is also building a reputation. So, everything you kind of do, all the projects you work with, the people you work with, the communities you work on, it's really important that, you know, you work well with others, and you build a reputation of being collegial and working well and solving problems when you can. I think the difficulty with kind of strategic things in Occupy Med is a lot of things aren't really solvable at a very quick way, you know. It takes years and years and years to get some solution for whatever the problem might be. Third, you know, really work on networking, and really networking is kind of what you do every day. And part of networking is, you know, volunteer to some degree. Obviously, not volunteering for everything is not going to work. I kind of volunteered selectively for different things, like deployments, you know. I found when I volunteered for deployment, just deploying itself opened up doors for other jobs in the military that if you didn't deploy, you really would, people would look at you funny, and where's your tab, and why you're in this room, because you don't have the experience or the necessary maybe skill sets from being deployed. So, and that, you know, part of building kind of your, you know, volunteering and building your reputation is building a team, because eventually you're going to leave your positions, and you're going to need somebody to eventually take over for your job. So, anyway, those are kind of my big snippets of advice for a career, for your career. So, this is my career in the Army. Sorry about all the acronyms. Dr. Barrett talked to me yesterday about my talk that I did yesterday, and he said, you have to spell out your acronyms, and I agree. It's just that if I spelled out every acronym on this, on my career here, it just wouldn't fit the page. So, this is my ability to do that. But I do want to talk a little bit about, even before I, you know, went to medical school, when I went to college, I actually thought I would go to pre-med. My dad was a surgeon, and that was kind of the path I thought I would go, you know. But then I went into ROTC, I got a scholarship, and then I thought, you know, oh, maybe I'd be an infantry and armor officer. It was fun. It was, you know, really cool to go out in the field and do these things in the Army, until I kind of discovered I really wasn't that great at kind of things in the field. It, you know, really kind of wasn't, you know, I had lots of peers that were, you know, amazing in, you know, things they did in the field and, you know, the Army stuff. You know, I did ranger, you know, the ranger kind of club in college, and it was a lot of fun. But I also kind of saw, like, you know, future-wise, you know, I just felt there was a better future if I went into medicine. So I went back to pre-med and graduated, and eventually, you know, went to the Uniformed Services University, not because it was the only place I had to go to, but I really felt it was the best fit for me and what I wanted to do, particularly in surgery. So I did a surgery internship at the Tripler Army Medical Center. That's what TAMCHI stands for in Hawaii. And honestly, Hawaii is not the best place to do surgery internship because you're really doing 100-plus hour weeks, as some of you might know, and, you know, it's kind of being in paradise and at the same time not being able to go to the beach at all because you're so busy, and when you're at the beach, you're too tired. So in some ways, not being accepted straight into residency in surgery was probably good for me because it gave me some time to figure out what I wanted to do. So I became a general medical officer in Germany, mainly doing primary care in a place called Hohenfels, Germany. I got deployed to Croatia, Hungary, and Bosnia, which is, you know, an incredibly interesting experience, and you learn a lot of things about yourself and about kind of the military when you do that. So good and bad, and I'll get into that later on. And then I went to another assignment out in Oregon at a place called Umatilla Chemical Depot, which is a small chemical weapons depot in northeast Oregon, and that's where I really got introduced to occupational medicine. It was a small clinic. We had workers that moved chemical munitions from one bunker to another. When they detected a leaker, they would, you know, compartmentalize the leaker, put in a specialized igloo, but the bottom line is that that was a job where it was bread and butter, med, it was highly regulated, you know. You had to know the regulations. You had to understand what the workers do and really make sure that the workforce is doing their job. So that's really what got me interested in OcMed, and then I eventually went into the residency program with the military, which was really the best decision in my life. After that, I was a command surgeon at a place called Joint Munitions Command, Army Field Support Command in Rock Island, Illinois. That acronym towards the bottom of the left side. And then I went to the National Guard Bureau as a chief of preventive medicine. I convinced the guard to send me off to flight surgeon school, and then I served in Kosovo as a flight surgeon. Then after that, I really did strategic jobs. I was at the Office of the Surgeon General, which is what OTSG stands for. I went to the Pentagon. Eventually, I went to the, I went into academics, and I was the associate program director at the Uniformed Services University, the OAM residency there for the military. Then went to Walter Reed while COVID was kind of at its last, middle to last stages, which was really interesting. And then finally, after I got out of the Army, after 30 plus years, I went to the VA. And I just felt that all these experiences, which I'm going to talk about, really set me up really well for my job at the VA, and I'll get into that in a bit. So I think one interesting thing about the military is that, you know, while you're in the military in OcMed, you know, your focus is on readiness, you know. It's all about are soldiers, are sailors, are Marines ready? And so a lot of what you do is, you know, is trying to understand the risk, the risky activities that all the different, you know, service members do. And in the end, I think OcMed, I mean, military medicine is occupational medicine, because really that's what the, you know, the medical side is supposed to do for the armed, you know, for the part of the armed services that actually goes to war. You know, and some of the things I did is I went to airborne school. Again, I became a flight surgeon. And just doing those different things, I think, really set me up to really understand, you know, kind of what, you know, what do pilots do, what do soldiers do when, you know, all my deployments, you know, you know, what do you, how do you live when you're deployed, you know. And certainly there were some very specific things. I think working in a chemical weapons depot was, you know, very unique, and I think coming out of that, you know, I knew, you know, nerve agents and mustard agents and what they can do to people, and also how to work with communities to respond to those, if God forbid you ever had to. And kind of the third bullet down here is just, you know, I think everything from my residency on kind of shaped my career. You know, when I was a resident, that's when 9-11 happened. That's when the anthrax scare happened in Congress. And then, you know, various other exposure issues that I was involved in while I was at the National Guard Bureau. That's when several states with National Guard soldiers, several years after the fact said, wait a second, what about our soldiers from the National Guard from our states that were exposed to sodium dichromate in Iraq? And so I had to basically track down all those states, figure out, you know, who was potentially exposed, and then almost helped develop a registry to track down and follow this cohort of exposures over time. And finally, when I was at the Pentagon, actually when I was at the Office of the Surgeon General for the Army, that's when the chemical warfare agents in the New York Times articles came out about, you know, different individuals in Iraq mainly that handled munitions that happened to contain chemical weapons. Some had nerve agents. Some had mustard. So that experience in Umatilla helped me to kind of be part of that effort, which was several months. And I'll talk about that in a bit. And I think in terms of networking, I think, you know, when I went to Uniformed Services, just, you know, talking with John Barrett and others down there about what I do and what I'm doing, eventually, you know, that kind of contact, eventually led to the job at the VA I do now. And, you know, I basically had to like, I could look at my resume, look at, you know, the job description for the, you know, obviously I think John had me, you know, had me and others in mind and basically just cut and paste my resume into that application to the VA. Which I think in some cases it's not that easy, but I was lucky because I think almost it was written for me and a few others where our careers kind of just matched up that job in the future. So again, just a couple pictures to show you what I did in the military, and I'll try to get through these in about five minutes, Steve, because I know I want to give you some time. But again, when I was in ROTC, we were still at war with the Soviet Union. We were still, you know, when I started off, we had olive drab uniforms, kind of like Vietnam era, and eventually went into BDUs or the other kind of the standard camouflage. And then towards the end of my college days, college years, I mean, the wall came down in Berlin. Then as a medical student, that's when the first Gulf War happened. Then thereafter, that's when issues occurred in Bosnia where I was deployed there. I was actually deployed to Croatia and Hungary for about 11 months doing mainly emergency medicine type work. I was on like on every third day working a 24-hour shift. The igloo or the bunker on the upper right, that was one of the bunkers in Umatilla, and that's a picture of our response team with the medics that we had to respond in case there was a disaster from the chemical weapons there. Again, 9-11 happened during my residency. After that, I went to, as I mentioned before, I became a command surgeon. One of the issues up with one of our subcommands was a place where they were making these thousand-pound bombs in the Midwest, basically the bunker buster bombs that they're designed to destroy deep into a bunker and find where the enemy was. But what was happening was that basically they were having a higher level of production and they weren't really wearing protective equipment that was adequate, and they were developing subclinical anemia because of that, and we found that once we actually, you know, they tried to engineer things out, et cetera, they really couldn't. The final solution was to put them in really encapsulated gear, and that really solved the subclinical anemia. So I think the big thing with that was, you know, again applying the principles of the hierarchy of controls, and again, how to figure out, you know, where did this subclinical anemia come from? And again, at the National Guard Bureau, I was involved with the Karmar League kind of tracking down cases and individuals that were potentially exposed to sydney dichromate, and I really felt that, you know, when I had to go to, for example, Indiana and talk to an angry crowd of National Guard soldiers and their families, you know, the risk communication skills that you learned in residency were critical in order to get through the crowd and make them understand, look, we're really trying to help you out. We're not trying to, you know, yes, I'm from the government, but here's what we're going to do to help you out as a cohort. And I already talked about my deployments a little bit. Obviously, burn pits was a big thing when I was in Afghanistan in 2013, and I think the big thing with that was that trying to communicate with leadership about what they should be doing with the burn pits, and it's very challenging when you're trying to manage a city of 20,000 people in Afghanistan, and I don't think burn pits is the top on your list of how to manage that big city, you know, among other things. So I was involved with the Individual Longitudinal Exposure Record when I was at the Office of the Surgeon General for the Army, Chemical Weapons, as I noted before, Academics as Associate Program Director for the Occupied Residency at USHUS, and I already talked about some of my experiences with COVID at Walter Reed and also at the summer camp for ROTC at Fort Knox. So again, some of the highs and lows of my career, you know, I had friends get married while I was obviously active duty. I got married while I was on active duty. I also served as the Consultant for Occupational Health and Environmental Medicine for the Army, and that's a picture of the Surgeon General giving me my consultant award, which I, you know, again, that's part of the volunteer advice that I had, because while it was like an extra half an FTE of work, I think it gives you kind of insights about the strategic level functioning of the military, and I think the even bigger thing, it allowed me to help my colleagues in Army Acmed to find good assignments and kind of serve as their representative. One kind of not so great thing or maybe good thing about being in the Army so long is that when I went into my retirement ceremony at Fort Myer, the formerly known as Fort Myer, I was the most senior colonel there, so I was actually the presiding officer, so I thought I'd be going in there and, you know, get the ceremony, but I had to actually get up there and lead the entire brigade, which was fun, but it was also more stress than I really wanted during that day, but we got through it fine. So again, I think in the military, apart from kind of the experience you have, you do lots of traveling, so I did two tours in Germany. Obviously, the food and the culture there was great. Got to go to, you know, lots of places like Italy while I was in Europe and travel, ski, go back to Oktoberfest and visit with some friends. When I was at Fort Knox as the chief medical officer for the ROTC camp there, I learned a little bit about bourbon and got to tour some of the bourbon there, bourbon distilleries there, but I think the most important thing was probably when my son was born a couple years ago or two years ago about, and that's where we are now. So I don't think I took up too, too much time, Steve, so I think I gave you enough time to talk to your partner. So thanks. Thanks, Joe. How many active duty folks here, by the way, if you don't mind? And how many veterans? Okay. So I'm going to sort of pick up the story here. When Joe was talking about the mission and healthcare in the military, and it's really about being mission ready, and the mission is the military mission, and when people transition out of active duty and become veterans, the mission, there's still a really important mission, but the mission really becomes their health and their future and their families and so on and their overall well-being. So I did not serve in the military myself. My father fought in the Battle of the Bulge. I grew up in a time where every home had a picture of the, usually the father, but I had not, that was in the Women's Air Corps as well, in the home when I was growing up. Because during World War II, one in every five households had someone in uniform. If you walked down the street, one in every five households had someone in uniform. And then I was in college during Vietnam. I had three friends on the wall. It was a very difficult time in so many ways, and certainly part of the reason I ended up working in the VA was because of my friends who were in Vietnam and because of my father and all of those who have served. So I looked at medicine as a trade, something I could just do anyplace and, you know, and help out and make a good living and so on. So after I finished my medical school, I did a rotating internship, became a GP. Back in the days, you could still become a GP. And I then went to Tanzania and worked for a year in an outpatient clinic, and I was trying to figure out what I wanted to do with medical training, with the skills that I had. And I was really interested in physical health care, like primary care or family medicine or internal medicine, but it wasn't the only thing I was interested in. I was really interested in psychiatry and mental health. And there wasn't really anything that was a good combination of the two. So for several years, I worked in a community mental health center. I set up a primary care clinic in a community mental health center, and I was trying to decide, you know, which way I wanted to go in my training, and I started moonlighting at the VA. And I went to the VA, and I was the M.O.D. It was called M.O.D., Medical Officer of the Day, and you would triage people if they needed to be admitted or just treated and sent on their way or whatever. And I did comp and pen exams. So compensation and pension exams, I'm sure almost all of you know, is a way of looking at experiences and health issues that may have come up while a person was active duty. And then they come into the VA, and we want to kind of get a basic understanding of what their health status is. And I thought, wow, this is really interesting, the idea of doing a health assessment when someone comes into your healthcare system that's based on the last healthcare system they were in and the last jobs they had. So really, C&P was kind of my intro into OCMED in a certain way. Because in addition to doing the comp and pen exams, they had these registry programs like the Agent Orange Registry, the Burn Pit Registry, Gulf War Registry. We had a registry program for former POWs. I had 325 former POWs that I took care of, mostly World War II, mostly Battle of the Bulge, actually. So I was getting a look at this population of veterans. All of us are really doing the same thing. We're helping individuals who have health consequences of jobs they've done or environments they've been in. So Michael's examples or Joe's examples. And every one of you, every day, that's what we're doing, is jobs people have done or activities they've had in environments that have risks as well. And we're trying to figure out how to kind of get things back on track. Well, I was fascinated by what was going on in the VA. And one of the registry exams they had was for Gulf War Registry. And I'm sure any Gulf War veterans here, by the way? Awesome. Okay. Any other Gulf deployed veterans? Not just Gulf deployed, I assume you mean? Yeah. So what we found was that Gulf deployed veterans were almost twice as likely to have medically unexplained symptoms. That was fascinating to me as well. What's going on here where individuals have medical symptoms, we work them up, we can't find an explanation, they're considered unexplained symptoms, Gulf War Syndrome, chronic multi-symptom illness, that fascinated me as well. So I was doing these registry exams, and then I thought, well, gosh, if we're going to do a registry exam, these folks coming back from the Gulf War, I felt like they were having a really hard time. Many of them were over there for nine months or so. The ground war was four days. So they got this message, well, it was only four days, wasn't that big a deal, wasn't that big a war. It was such a misunderstanding of what deployment's all about and how combat and deployment in general can affect people's health. So we set up a clinic. It was called the Gulf War Veterans Clinic, and we started out by doing this registry exam, which was doing an inventory of activities and exposures they endorsed while they were in the Gulf, and there were dozens of them. You know, they were taking prophylactic medications for nerve agents, and they were taking antimalarials, and there were dust storms, and there were burn pits, and there were oil well fires, and scud missiles with chemical weapons, and people were taking protostigmine bromide for chemoprophylaxis. And so the clinic that we set up was looking at what happened to you when you were deployed, when you were in the Gulf War. We started with that, and then we sort of looked at, okay, what can we do to help you get you back on your feet? And that's the, all of a sudden I realized, yeah, this is occupational. We're trying to get an injured worker back on their feet and back into a healthy trajectory in their life. So that's how I ended up. So I was 50 years old at this point. Went back and did my training in occupational environmental medicine. And so I'm thinking about each one of you, too, because all of us have had very interesting trajectories getting into this field, and it's a field that's got fascinating potential. If you do internal medicine, you become a pulmonologist, you do your fellowship, and you do, you know, pulmonology the rest of your life, you know, that's a great thing to do. This kind of is overarching, you know. It involves anybody with any health concern that could potentially be related to jobs they've been doing, activities they've been doing, or environments that they've been in. So that was, you know, that's how I ended up here. And just like many of you, we've had these interesting trajectories. And then how do we put it to work? So in addition to the Gulf War Veterans Clinic, then we started the idea of post-deployment care as a thing and not a bunch of stuff. In other words, when a person, and I have a slide here to show in just a minute, but when a person comes back from deployment, the risk exposures include TBI, chemical weapons, high-impact noise, physical injury, psychological trauma, moral injuries, all of these things happen at the same time. And so we decided, how do we put together a care platform that kind of integrates all of these different concerns and tries to take care of them in a systematic way, essentially, again, to help this worker get back on their feet and back to their life? So, yeah, so this, you know, these are just rationalizations, again, for why I thought OEM in the service of veterans, it's just a perfect kind of training and a perfect kind of lens through which to look at veterans and their health concerns. And, you know, high-risk, they've all been doing high-risk activities in high-risk environments, post-deployment care is really like kind of a specialized rehab clinic, in a way, for individuals that have all these health concerns related to the deployment, their lives have been turned upside down. The idea of service connection is kind of like worker's comp, in a way, it's very specialized, it's very elegant, in a way, what we have to offer to veterans in terms of support for health conditions they have that could be related to their prior work and their prior environments, and so on. So, then the PACT Act came along, and you've probably all heard about it and knew about it before, and maybe you've been to some of the sessions, but it gave us this opportunity to look at exposures in particular, and we got good funding and good support, and one of the sections of the PACT Act was, we want you to screen every one of these 8.6 million veterans for health concerns potentially related to exposures. So, I was sort of thinking, all the training that I did in my MPH and OCMED was put to work in trying to figure out how are we going to do this, how are we going to screen 8.6 million veterans. So, the position I'm in now is as the physician lead for this screening project in VA. PACT Act, there have been other sessions on this, but it supported healthcare and resources for veterans with exposure concerns in many ways. So, in a way, for OCMED, I feel like what we're doing in the VA has potential benefit for larger populations as well. We're looking at people living in environments that are toxic in so many ways, we're trying to figure out how do we support them. It's not just veterans. So, I'm feeling like much of what we're doing in the VA has applications beyond the VA as well. So, post-deployment care, essentially what we were saying, and I was saying before, it's not a bunch of stuff. Someone comes in, you screen them for PTSD, you send them to mental health, they're not going to go to mental health, they don't want to talk about PTSD, or you send them for their TBI, it's like it wasn't working. And so, you know, we really needed an integrated system of care, and the VA has put together this platform, we call it veteran-centered. It's not patient-centered, veteran-centered, which means it's about the veteran, their service, things they've experienced, and how it's affected their health. That's the basis of VA care, veteran-centered, team-based, and you know, who knows more than some, than veterans, particularly those that have been deployed in combat, for sure. If you don't have a team that's working together, it's not annoying, it's life-threatening, it's scary. And so, we feel like we need an environment that's veteran-centered, it's team-based, it's integrated, the pieces are put together, and it's whole health-oriented. Because the mission now is the best way you can mitigate any long-term impacts of exposures, for example, is by having good, ongoing, exposure-informed, we use that term exposure-informed care, that's whole health-oriented. Healthier you can stay over the years, the less problems you're going to have with any residuals of any exposure. So, whether we're talking the individual veteran, they need that packaged up within the red circle, or population health. So, we look at the whole veteran population, 8.6 million enrolled, and there's about 18 million or something, I think, is that right, Eric, something like that, total 18 to 19 million veterans. So, only about half of the veterans are actually enrolled in the VA. So, the last slide, yeah, the last slide I wanted to show here was how I think using the principles and practices about occupational medicine can really serve well in the veteran's healthcare system. And actually, Michael and I kind of cooked this up 10, 15 years ago, because these are the sorts of things that go on in the VA and in veteran's healthcare. And that includes compensation and pension, it's kind of our compensation package, workers' comp, post-deployment care, which really, in a way, really benefits from this lens of occupational environmental medicine, the registry programs that Eric, Dr. Schooping's in charge of, that he's doing amazing work to kind of transform them into something that's more effective and more useful for the veterans, training, I have residents with me, and we have not only the OCMED residents, but also primary care residents rotate through the clinics. So, they also learn how to take care of veterans in veteran's healthcare and so on, because we really want to remember that taking care of veterans is not just the VA responsibility, it's a national responsibility. So, one of the things going on right now in the VA is we screen all enrolled veterans. So, if you're seeing a veteran in your practice, and if you're seeing adults, you're seeing veterans, if you ask, you're gonna find out that a significant number are veterans, you can let them know that the VA has this going on. Our goal is to screen every enrolled veteran, and if they're eligible for certain sorts of resources and benefits, we want to make sure they get hooked up with it. So, it's a good way of collaborating with your local VA, call your local VA if a veteran wants to be screened. If they're not enrolled and want to enroll just to be screened, they can do that as well. And 60% of the veterans get some of their care in the VA, some of their care outside the VA. So, we look at veterans' healthcare as really being more of a collaborative effort than just what happens at the VA. So, I would encourage you, if you have any veterans, when you identify veterans in your practice, to encourage them to take advantage of this screening. Excuse me, I got asthma after all the wildfire smoke in the Northwest a couple years ago. We had two years of bad, there were a couple days it was the worst air on the planet, was in Seattle, believe it or not. So, this idea also in VA of what we're trying to do with exposure-informed care is we screen every veteran for these most common exposures, but they also may endorse other exposures. Thanks, Michael. Like fuel, jet fuels, or solvents, or hydraulics, everything you can think of they use in the military. And these other exposures, if we don't have presumptive conditions, then they have to go through the usual track of an exposure assessment, which is very difficult because we don't have exposure data for most of these exposures. So, it becomes much more complicated. So, we have these veteran-centric policies, which aren't science, they allow for service connection on a presumptive basis. We have no idea who is exposed to how much for how long. We just say, if you were in the same place as the chemical at the same time the chemical was there, we presume you were exposed. And if there's any evidence, IOM used to do this, now NASEM, any evidence, even if it's just minimal, but suggestive in terms of studies, that's good enough for us. We're not gonna assume, we're gonna say if it might have hurt you, we're gonna assume it could have hurt you, and you're gonna be supported for that association. And at the same time, we'll say to a veteran, you know, you may well get service connected for your hypertension because of Agent Orange. And I say this every day, I've said this every day for decades, but you can't say that Agent Orange caused your prostate cancer. You can't say that Agent Orange caused your hypertension. What you can say is you almost surely were exposed because of where you were, and you even saw stuff going on. So we assume you were exposed, and it's possible this might have contributed to this condition. So it's precautionary principle. It's not proof of, it's not a nexus. It is a veteran leaning, giving the veteran the benefit of the doubt of a potential association. So all of the, I mean, I feel like the luckiest guy in the world because I'm doing all these things all the time. I have the residents with me, employee health, help out with employee health. We're educating employees, we're educating veterans. We do consultations for staff and so on. So this is just a way that I feel like our practice, our discipline can be useful in the VA. And you know, just listening to you, Joe, talking about how it's useful in active duty and Michael, the work you've done with workers through OSHA and your work in the VA is remarkable as well. So I wish everyone could hear, could sort of describe the trajectory of their entry into this field and ways that you think we might be able to expand the relevance of occupational health and occupational environmental medicine because I think it's grossly underappreciated. It's grossly, you know, and in fact, this idea of exposure informed care, I think will be led by OEM and primary care folks, family docs, other primary care folks working together to always factor into a person's health evaluation and healthcare, the potential for environmental contributions, physical environmental predictors of health, just like we have social determinants of health. We also will have physical environmental determinants of health, not just for veterans, but for the population in general. And when we start thinking about monitoring environments for particulates, just like we do for firefighters, there may be a time when we can monitor exposures in the combat environment or the deployment environment or just in general. So we have a closer idea of what we're all being exposed to at various times during our lives in this environment of environmental degradation, which we've been talking about throughout this session. So Joe and Michael, I don't know if you wanna make any other comments, but we're very interested in anything, you know, any comments you all might have and how we might be able to. We have five minutes, so if you wanna ask a question, just come up to the mic here and ask it or have anything you wanna discuss that we, you know, about our careers. Anybody? And while we're waiting, I wanted to, I gave the negative sides of OSHA work. I think as public health practitioners, we do population management. And I think one of the big things that government work has let us, and certainly the three of us here, do in ways that is very hard to do, even from an academic or a private sector thing, is to use the power of an institution to induce change. So both Steve and Joe went through their careers at length. The VA, when I was led occupational health, invented what we now think of as safe patient handling and violence prevention and healthcare. Those programs simply didn't exist before. Without VHA's leadership at the time, it's, you know, science moves forward. At some point, somebody would have implemented that. The first patient handling equipment was patented in 1911. So it's not that VHA invented the idea, but putting it together. And so working in an institution gives you a lever that doesn't exist outside of those institutions with all of the weaknesses of institutions. Any other questions or comments? We really appreciate your being with us here today. And, oh, please. So I enjoyed hearing about OSHA perspective and the PAC-EC and the assignment that's going on in the VA. Is it turned on? Can you see? It should be turned on, but it could be turned off. So, hi. Hello. So, I really enjoyed hearing about the OSHA perspective and VA perspective. And I can hear the excitement from the VA side of the PAC-EC. And I was very surprised to hear about OSHA and moral dilemma that people are experiencing. I am a resident and I'll be rotating in OSHA next year. And when I think about OSHA and occupational medicine, I was like, wow, OSHA is the federal government. So this organization exists for the people. This is the organization that really tries to protect the public. Whereas if you think about the company doctors, they are in a position of conflict of interest. You have to balance the C-suite and then you want to help the workers. And I was like, wow, federal government must be so much better because you know exactly who you are serving. You're serving the public. But it's very shocking to hear about this. But I think one thing that I find interesting about this is that when I see a lot of cancer cases and stuff like that, workers' compensation, establishing it is so difficult. And PAC-EC has breached that gap, that nexus is so difficult to establish. And I know there's politics and all those things that influence all this. But I wonder, PAC-EC can serve as a little bit of model of how we should deal with people who get injured from their job. If somebody will get a job for a long time and develop certain conditions, some kind of presumption. I don't know, but I was just thinking about it. That is our hope for sure is that we can have policies that aren't based on data and science. They're based on values and mission. And if we have policies that lean towards workers or lean towards the environment and use this precautionary principle, which is if it looks like there could be a problem, stop. Let's not keep going until things go down the hill. So we do hope that. And Michael, did you wanna make a comment about OSHA? Workers' comp programs are all state-based federal law. The OSHA Act prohibits OSHA from considering state law and economics. So, does this one work better? Yeah, there you go, that's better. Sorry, paragraph 4B4 of the OSHA Act is very clear about that. And so the question of how we in this country get at that is a big issue. One of my retirement projects is in fact to do comparative regulatory philosophy in countries that are structured very differently. So in this country, we forget that Bismarck, not anybody's idea of a liberal, created workers' compensation and social insurance programs in the Kaiser Reich in 1870 as a bulwark against the communists. And so as we think about the social fabric of countries, understanding what we really want and who owns what solution, it's a long political process. And doing something like the PACT Act is not an overnight or even a decade's worth of work. I would also comment really quickly that I think veterans, it's a very special population where politically it's much easier to get that, whereas a place like Germany where, again, I think the social fabric of Germany supports workers much better than, say, the United States. I don't know if you'd agree with that, Michael. Michael, I have a question or just a comment about in Washington State, the Labor and Industries accepts undocumented workers who are injured. The claim, there's no distinction for undocumented workers. And in fact, WISHA, the OSHA state agency, has investigated farm employers regarding violations. That's my understanding, anyway. Yes, the problem is that, let's say three people get hospitalized and they are undocumented workers. They get hospitalized and their hospitalization gets paid. OSHA has an agreement with INS to not deport people until after our OSHA citation is issued. But once that citation is issued, those workers have no right to treatment in most states and INS will deport them. I stand corrected. I think that's the end of our session, so thank you, everybody, and I'm gonna stand around if anybody has any questions about Michael or Steven. But anyway, thanks again. Have a great day. Thank you.

Steve Hunt

physician

Seattle

toxic exposure screening

veterans

occupational and environmental medicine

OSHA

military healthcare

exposure-informed care

federal organizations