Transcript Diapositiva 1

Agent Orange and End Organ Disease
My experiences as a veteran, patient, and a health care provider.
Hans White, PA-C
What Does Agent Orange Do?
• After Agent Orange exposure, this dangerous chemical
(Dioxin) begins to accumulate in the fatty tissues of the
body and stays in a person's body for a long period of
time. It can cause many diseases and in the end could
cause death in humans. One of the most devastating
disease is type II diabetes and diabetes will be the root
cause of every other problem the veteran could and will
have.
• For our purposes I follow the link from Agent Orange to
Diabetes and it’s many problems.
Agent Orange
• Agent Orange is an herbicide that was used
from the 1940s through Vietnam War in the
1960s. Agent Orange is a defoliant and
herbicide when sprayed on plants, it causes
them to die. Scientists found that it contains a
very dangerous dioxin. It was later suspected
that people who were exposed to Agent Orange,
including American soldiers, were at risk of
dioxin poisoning.
Agent Orange Act
• In 1991, the United States Congress passed the Agent
Orange Act, which stated Vietnam War veterans who
were diagnosed with medical conditions stemming from
Agent Orange exposure would be treated and
compensated.
Agent Orange Presumptive
Diseases
• Although there are many medical problems
related to Agent Orange, the VA only considers
the following listed medical problems to Agent
Orange as presumptive diseases.
•
Amyloidosis, Chronic B-cell Leukemias, Chloracne (or similar
acneform disease), Diabetes Mellitus Type 2, Hodgkin’s Disease,
Non-Hodgkin’s Lymphoma, Ischemic Heart Disease, Multiple
Myeloma, Parkinson’s Disease, Peripheral Neuropathy **** Also
associated with diabetes late-onset. **** Porphyria Cutanea Tarda,
Prostate Cancer, Respiratory Cancers (includes lung cancer), Soft
Tissue Sarcomas
What is Diabetes Mellitus?
• Diabetes mellitus is characterized by high blood sugar
levels that result from defects in insulin secretion, or its
action, or both.
• Elevated levels of blood glucose levels are tightly
controlled by insulin, a hormone produced by the
pancreas. Insulin lowers the blood glucose level. When
the blood glucose elevates (for example, after eating
food), insulin is released from the pancreas to normalize
the glucose level. In patients with diabetes, the absence
of insufficient production of or lack of response to insulin
causes high blood sugars (hyperglycemia). Diabetes is a
chronic medical condition, meaning that although it can
be controlled, it lasts a lifetime.
What are the chronic
complications of diabetes?
• Diabetes complications are related to blood vessel
diseases and are generally classified into small
vessel disease, such as those involving the eyes,
kidneys and nerves (microvascular disease), and
large vessel disease involving the heart and blood
vessels (macrovascular disease).
Diabetes
Diabetic Retinopathy
Leads to blindness
Ischemic
Heart Disease
(heart attack/stroke)
Diabetic Nephropathy
Kidney disease leads to
dialysis
Diabetic
Peripheral Artery
Disease
Diabetic Neuropathy
Leads to loss of
sensation
Leads to lost
toes/feet/legs
Complications of DM - Eye
• Eye Complications
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The major eye complication of diabetes is called diabetic retinopathy. Diseased
small blood vessels in the back of the eye cause the leakage of protein and
blood in the retina. Spontaneous bleeding from the new and brittle blood vessels
can lead to retinal scarring and retinal detachment, thus impairing vision.
Approximately 50% of patients with diabetes will develop some degree of
diabetic retinopathy after 10 years of diabetes, and 80% of diabetics have
retinopathy after 15 years of the disease. Poor control of blood sugar and blood
pressure further aggravates eye disease in diabetes.
Cataracts and glaucoma are also more common among diabetics. It is also
important to note that since the lens of the eye lets water through, if blood sugar
concentrations vary a lot, the lens of the eye will shrink and swell with fluid
accordingly. As a result, blurry vision is very common in poorly controlled
diabetes.
Complications of DM-Kidney
• Kidney damage from diabetes is called diabetic nephropathy. The
kidneys lose their ability to cleanse and filter blood. The
accumulation of toxic waste products in the blood leads to the need
for dialysis. Dialysis involves using a machine that serves the
function of the kidney by filtering and cleaning the blood. The
progression of nephropathy in patients can be significantly slowed
by controlling high blood pressure, and by aggressively treating high
blood sugar levels.
Complications of DM-Nerve Damage
• Nerve damage from diabetes is called diabetic neuropathy. In
essence, the blood flow to the nerves is limited, leaving the nerves
without blood flow, and they get damaged or die as a result .
Symptoms of diabetic nerve damage include numbness, burning,
and aching of the feet and lower extremities. In later stages a
complete loss of sensation in the feet occur, patients may not be
aware of injuries to the feet. Because of poor blood circulation,
diabetic foot injuries may not heal. Sometimes, minor foot injuries
can lead to serious infection, ulcers, and even gangrene,
necessitating surgical amputation of toes, feet, and other infected
parts.
Complications of DM-Nerve Damage Cont.
• Diabetic nerve damage can affect the nerves that are important for
penile erection, causing erectile dysfunction (ED, impotence).
Erectile dysfunction can also be caused by poor blood flow to the
penis from diabetic blood vessel disease.
• Diabetic neuropathy can also affect nerves to the stomach and
intestines, causing nausea, weight loss, diarrhea, and other
symptoms of gastroparesis (delayed emptying of food contents from
the stomach into the intestines, due to ineffective contraction of the
stomach muscles).
• The pain of diabetic nerve damage may also improve with better
blood sugar control, though unfortunately blood glucose control and
the course of neuropathy do not always go hand in hand.
Diabetic Vascular Disease
Diabetic vascular disease refers to varying medical issues with
veins and mostly arteries in the development of blockages in the
arteries, sometimes called “hardening of the arteries”. This could
and in the end develop serious health conditions, including
blindness, severe kidney disease, stroke, heart attack, or sores
in your feet. Eventually, if you develop dead tissue, which is
known as gangrene, it could lead to infection and ultimately to
amputation.
What is atherosclerosis?
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Atherosclerosis is a gradual process whereby hard cholesterol substances
(plaques) are deposited in the walls of the arteries. Cholesterol plaques cause
hardening of the artery walls and narrowing of the inner channel (lumen) of the
artery. This process usually begins early in life, However, is escalated by other
human issues such as Agent Orange and diabetes. Therefore, many adults
typically are unaware that their arteries are gradually accumulating cholesterol
plaques. When it becomes advanced with aging, it causes critical narrowing of
the arteries resulting in tissue ischemia (lack of blood and oxygen).
Arteries that are narrowed cause diseases in different organs. For example, the
coronary arteries which supply blood to the heart muscles can lead to heart
attacks. The carotid and cerebral arteries (arteries that supply blood to the brain)
can lead to strokes and transient ischemic attacks (TIAs). The lower extremities
can lead to pain while walking or exercising (claudication), deficient wound
healing, and/or leg ulcers.
Heart Disease
•
Heart disease is the leading cause of mortality in the Western World.
The term coronary heart disease also referred to as ischemic heart
disease which by itself is a presumptive disease associated with Agent
Orange refers to a condition whereby the heart itself is deprived of an
adequate oxygen supply. It is usually caused by he narrowing of
coronary arteries. Whilst the function of the heart is to pump
oxygenated blood around the body, the heart tissue itself must be
supplied with oxygenated blood to survive. As the fatty deposits
accumulate, the arteries become narrowed and the amount of blood
that can pass through them is reduced. If a coronary artery becomes
blocked, the patient will suffer a heart attack and if the heart is deprived
of oxygen for long, irreversible damage to the muscle will result. It is a
common cause of congestive heart failure. The risk of the condition
increases with: age; a familial history of the disease (i.e. a genetic
component); smoking; dietary factors (notably, a high cholesterol diet);
diabetes; and high blood pressure.
VA Form 21-0960A-4 Oct 2012
Conditions that increase risk for
coronary heart disease
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Sleep apnea. This disorder causes you to repeatedly stop and start
breathing while you're sleeping. Sudden drops in blood oxygen levels
that occur during sleep apnea increase blood pressure and strain the
cardiovascular system, possibly leading to coronary artery disease.
Obesity. Excess weight typically worsens other risk factors.
Smoking. Nicotine constricts your blood vessels, and carbon monoxide
can damage their inner lining, making them more susceptible to
atherosclerosis. The incidence of heart attack in women who smoke at
least 20 cigarettes a day is SIX TIMES that of women who've never
smoked. For men who smoke, the incidence is TRIPLE that of
nonsmokers.
Metabolic syndrome — a cluster of conditions that includes elevated
blood pressure, high triglycerides, elevated insulin levels and excess
body fat around the waist — increases the risk of coronary artery
disease.
Procedures to restore and
improve blood flow
• Angioplasty and stent placement
(percutaneous coronary revascularization). This
can be done in the legs too.
• Coronary artery bypass grafting
(CABG) surgery. Bypass grafting can also
be done to the arteries of the legs to restore
proper flow to them.
Complications of DM Peripheral Vascular Disease
• Peripheral vascular disease (PVD) refers to diseases of
the blood vessels (arteries and veins) located outside the
heart and brain. While there are many causes of
peripheral vascular disease, doctors commonly use the
term peripheral vascular disease to refer to peripheral
artery disease (peripheral arterial disease, PAD), a
condition that develops when the arteries that supply
blood to the internal organs, arms, and legs become
completely or partially blocked as a result of
atherosclerosis. This often leads leg and foot ulcers to
worsening of nerve damage, and ultimately the loss of
toes, feet and legs.
Atherosclerosis of the legs
Medical tests your doctor may
perform
• Cardiac conditions:
• Electrocardiogram (ECG) and Holter (an ECG that you wear
around for a day or two).
• Echocardiogram. This is an ultrasound of your heart that looks at
the structure.
• Exercise Stress test. This can also be done without exercise.
• Cardiac catheterization or angiogram. **GOLD STANDARD**
• Heart scan. Computerized tomography A CT coronary angiogram
• Magnetic resonance angiography (MRA). This procedure uses
MRI technology, often combined with an injected contrast dye.
Testing cont.
• Peripheral Vascular Diseases:
• Ankle Brachial Index (ABI) and/or Doppler Flow
Studies. These are tests that are done if your legs hurt
when you walk and your calves cramp.
• Duplex Doppler Ultrasound
• Venography
• MRI/MRA
• ABI
Testing
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Basic Testing
Laboratory
Basic Radiology - X ray
Advanced imaging – CT, MRI, MRA, PET
and more
Lung problems your provider may order PFT
< ASK WHICH TEST ARE FOR YOUR
CONDITION/s AND HAVE THEM RUN THE
DEFINATIVE TEST>
Advice to the Veteran
• Write down/List all of your medical
problems – If wondering what to write
down - Don’t think about it, don’t ask
yourself if you should or shouldn’t, if this is
something they want or they don’t want –
just write it down!
More advice
• Do not take your medical providers at their
word. Many times they will say “oh that’s
ok it is just arthritis” or “that’s just part of
getting older”. Be proactive, ask questions
• If you disagree seek second opinion.
• Request specialist referral
• Ask for and keep copies of all visits and
tests
Veterans duty
• Go on line to the VA sites, Best site is: 38
CFR C SHEDULE FOR RATING
DISABILITIES. Look up your medical
issues, read the criteria, make copies and
bring them to you health care providers.
• Most civilian providers know nothing about
VA disability or Social Security disability
and want nothing to do with it.
Civilian vs.VA Health Care
• There is a difference; however not for
long.
Let me tell you about Health
Care Providers and our
health care system!
• Most have the best intensions, many do
not
• Some are smart, many are not.
• For most people the system no longer
allows for personalized in-depth care
Let me tell you about the VA
• Medical care at the VA is just about the same as in
the private sector – not !!!
• Many providers, ancillary staff from nursing to house
keeping are generally proficient and caring.
• Administration; mid-level and down ward are just like
you and me. Some senior administrators do the best
they can in a system that is dysfunctional.
• Overt problems consist of long waits for
appointments, changing providers, getting tests
approval and appointments in a timely manner.
• Covert problems – well you hear the news, VA
sending to out side providers will make it worse.
Let me tell you about the VA
some more
My story
Thank you, thank you, thank you Mrs. VanVliet my VA rep. I could not
and probably would not have completed the process without her. I have
learned much from her and I, my family and my veteran patients thank
you.
My fault – Disorganized and lazy.
And what is the VA’s fault
EVERYTHING
•EVERYTHING
My story some more
My first and only visit to the VA; courteous,
professional and strange.
Hearing test – fell asleep, need two hearing
aids, not service connected
One provider one visit one day
One fine day; I come home and find a opened
envelope from the VA. I ask my wife what it was
and she said “ I looked it over and could not
understand it, it is all confusing”.
90%, 90% of what?
more
• Over the following month I received many more
envelopes from the VA – confusing
• I complained to anyone listening about the stupidity of
the VA
• I find out about e-benefits, sign up(what a strange site)
and recheck every so often. Development Letter Sent
Two weeks later the same 4 weeks later the same, I called
told they wanted something however he did not know what.
He will make a note to have the letter sent again.
more
• Development letter received, something's
real other things not so real- gave them
what they wanted
• Telephone calls Idaho, Mississippi and
Florida
• Provider assignment
• Due date May 2014, Due date November
2014, Due date sometime 2015
Reality
• I and many others complain about the VA
medical system, much is justified although
not all.
• Many men and women have received help
relieving themselves and family from
significant burden.
Thank you
• From the bottom of this old Veterans heart;
You have impacted many lives and I know
you will do so in the future.
• I thank you all for what you do.