Guest guest Posted May 11, 2006 Report Share Posted May 11, 2006 This was posted by a member of Chemical-Illnet. This is only the first part. The whole is at the url. blessings Shan Defining Chemical Injury http://www.iicph.org/docs/ipph_Defining_Chemical_Injury.htm A Diagnostic Protocol and Profile of Chemically Injured Civilians, Industrial Workers and Gulf War by G. Heuser, M.D.,Ph.D. , P. Axelrod and S. Heuser, M.A. Correspondence to: G. Heuser, M.D., Ph.D. 28240 W. Agoura Road, Suite #203, Agoura Hills, California 91301, Fax: (818) 865-8814, or P. Axelrod, 2601 N Street, No. 3, Sacramento, California 95816, (916) 441-4397. IPPH Volume 13, Fall 2000; Pages 1-16 [iSSN # 8755-5328] Table of Contents ABOUT THE AUTHORS INTRODUCTION HISTORY PHYSICAL EXAMINATION CENTRAL NERVOUS SYSTEM PERIPHERAL NERVOUS SYSTEM AUTONOMIC NERVOUS SYSTEM EYES NASAL AND PULMONARY PASSAGES GASTROINTESTINAL SYSTEM SKIN IMMUNE FUNCTION ENDOCRINE SYSTEM REGULAR LABORATORY STUDIES TOXICOLOGICAL CONSIDERATIONS CONCLUSIONS SUMMARY ACKNOWLEDGMENTS ABBREVIATIONS REFERENCES ABOUT THE AUTHORS Dr. Heuser practices clinical toxicology. He has seen thousands of patients after toxic chemical exposure and over time developed and used a diagnostic protocol, which objectively documents chemical injury and impairment. Heuser has published many peer reviewed articles, contributed book chapters, and has been internationally recognized in his field. He has been invited to present his diagnostic protocol in Australia, before the German government (Bundestag) in Bonn, at the Karolinska Institute in Stockholm (Sweden), and before the Annual Conference of the National Gulf War Resource Center. Patricia Axelrod directs The Desert Storm Think Tank and Veterans Advocate which is an ad-hoc association of active duty, reserve and retired soldiers, scientists, and researchers working together to assess the impacts and consequences of war in general with a specific emphasis on The Persian Gulf War. Axelrod's work has assisted in American, German and United Kingdom governmental investigation and reform. Her work has received a Project Censored Award from the Sonoma State University, Sonoma, California. She is also the recipient of a 1990-91 John D. and Catherine T. MacArthur Foundation Research and Writing Grant,which helped seed The Desert Storm Think Tank. Her 1993 ground breaking article, «Research Guide for Desert Storm Syndrome (International Perspectives in Public Health Vol. 10, 1994) has been entered into the records of a number of U.S. funded committees for the investigation of Persian Gulf War illness, including those conducted by Senator Donald Reigle, the National Institutes of Health, and the Presidential Advisory and Oversight Committees. In preparation for this article Axelrod traveled to and from post-war Baghdad, Iraq. In addition she has interviewed and debriefed hundreds of Persian Gulf Veterans. Both Heuser and Axelrod are founding members of the State of California, Reserve Officer Association committee on Persian Gulf War Illness. Sylvia Heuser is president of EMRIC (Environmental Medical Research and Information Center) which is based in Dr. Heuser's office and supports all his research and writing projects with ideas, literature search, and review of patient files. INTRODUCTION Chemical injury can cause severe, often disabling multi-system complaints, which may persist for months and at times years after chemical exposure has ceased. Physicians who see chemically injured patients are frequently baffled when they face a patient with multiple complaints, which do not fit into a known diagnostic disease category. Furthermore, regular laboratory tests (e.g. CBC, liver function tests, sedimentation rate, urinalysis) are often normal as is a cursory physical examination. The diagnostic exploration of a chemically injured patient is a new field, which is difficult for the inexperienced physician. Chemically injured patients often complain of impaired cognitive and memory functions, intermittent confusion and disorientation, changes in behavior and mood, word-finding problems, sleep disorders, decreased libido and potency. At times they complain of seizure-like events. They also often report recurrent flu-like symptoms, fatigue and exhaustion, malaise, headaches, and chronic pain. Skin rashes, gastrointestinal complaints, and other health effects may also be present. Different patients may react differently to a given chemical or group of chemicals. Toxic effects cannot be objectively evaluated unless every involved system is studied with advanced and sophisticated methodology. Without benefit of that process, a chemically injured patient will be dismissed with a diagnosis of post- traumatic stress disorder, somatization disorder or other labels implying that «it's all in their heads» [Davidoff, et al., 2000]. The largest patient population to have received such a diagnosis is that of the Persian Gulf War Veterans. As of the writing of this article, nine years after the armed conflict, several hundred thousand veterans still suffer from a host of symptoms called «Persian Gulf War Illness» which may in large part be due to chemical injury [Jamal, 1998; Everson et al., 1999]. The authors understand that war time in Iraq exposed people not only to chemicals but also to uranium 238, a.k.a. depleted uranium, electromagnetic radiation, experimental vaccines, pyridostigmine bromide, biological warfare agents, and diseases and parasites indigenous to the Middle East e.g. leishmaniasis and brucellosis. Any of these toxins and infectious agents, individually or in combination, may carry with it a host of health effects. The purpose of this paper is not to dismiss those impacts but rather to offer currently available diagnostic techniques which, if applied correctly, will help both patient and physician assess how a toxic environment alone may contribute to illness otherwise dismissed as psychosomatic. In this paper we will guide the reader through a diagnostic protocol which the senior author has developed and used on thousands of his chemically injured patients. We propose tests and consultations (from experts in their respective fields) which from our experience and research are most helpful in documenting and at times quantifying the effects of toxic chemical exposure. In discussing our approach, we will take one organ system at a time, discuss and select diagnostic tools and tests appropriate to the evaluation of a given system. Single abnormalities in a single system can have many causes. Abnormalities in multiple systems can also have many etiologies. However, a careful differential diagnosis (using this suggested protocol) will arrive at a tenable diagnostic impression of chemical injury if multiple objective abnormalities are found and cannot be explained on any other basis. Thus, a diagnosis of chemical injury is arrived at in part by exclusion of other diseases, which may have predated the toxic exposure in question. In the experience of the authors there is no doubt that chemical exposure (solvents, pesticides, chemical weapons, others) occurred during the Gulf War. In this sense, Gulf War Veterans deserve the same careful evaluation which is indicated in patients who have been exposed to chemicals at home, at work, or elsewhere (e.g. commuting) here in the USA. The protocol begins with an exhaustive case history, to be followed by a careful physical examination, laboratory tests, and specialty consultations. Patient and doctor should seek out consultants who display interest rather than indifference. Generally an enthusiastic, curious and interested consultant specialist will be a better member of the evaluation team and bring his or her methodology to bear when tackling the problem of diagnosing chemical injury. The evaluation process ends with case definition and a better understanding of the patient's problems and needs. Most importantly, this process will lay the foundation for rational and compassionate treatment. This paper does not address the experienced clinical toxicologist. Rather, it is meant to help the personal physician to follow a road map of investigation when facing a patient who presents with a history of chemical injury. This paper is also meant to help the educated layperson who has been chemically injured and is being told that nothing is wrong since nothing abnormal can be found (on minimal testing only!). In our experience, both the general physician and the educated patient need a guide to follow when trying to understand and evaluate a toxic situation. This paper is meant to function as such a guide. The need for a road map is especially urgent since society is pressured by some of its segments to attach a psychiatric diagnosis to some patients and to then hospitalize them with that diagnosis. HISTORY Histories as well as the physical examinations are meant to guide the clinician into the process of a differential diagnosis in which certain conditions are tentatively accepted or rejected. Appropriate testing will then follow and rule in or out conditions and diseases in a given patient. An individual and family history must be carefully obtained from the patient. Past and present conditions and diseases (incl. those of childhood and connected with occupation), as well as past and current occupational, incidental or accidental chemical exposures should be listed. Short-term memory loss is present in many patients and therefore at times makes them poor historians. Thus it is desirable to engage support from family members and significant others to participate in the history, which may then be more correct and complete. Patients should be encouraged to list what appear to be «allergic» or «sensitive» reactions to chemical substances, which were previously not experienced as harmful. These include chemicals such as gasoline, fumes and perfumes, household cleaners and other chemicals in everyday use. Reactions to these chemicals may include skin rashes, hives, eye and throat irritations, sinus problems, nausea, dizziness, and flu-like symptoms. These may have developed during the initial chemical exposure but may also recur when a patient has become chemically sensitive and now reacts to even low amounts of a given chemical or chemical mixture. This reaction to low level exposure is called Multiple Chemical Sensitivity (MCS) [Cullen, 1987]. If not carefully evaluated, MCS patients will easily be misdiagnosed as suffering from somatization disorder, post-traumatic stress disorder or other psychiatric labels. Patients with a history of chemical injury may develop chronic fatigue [behan, 1996; Bell et al, 1998; Buskila, 1999; Dunstan et al, 1995; Heuser, 1993; Tirelli, 1998] (incl. Chronic Fatigue Immune Dysfunction Syndrome (CFIDS), chronic pain (incl. headaches and fibromyalgia), intermittent dizziness and faintness (especially after prolonged standing), and other significant and at times disabling symptoms. A complete history should list all of the above and all additional problems the patient has. Patients should also be asked to obtain all existing civilian and/or Department of Defense and Veteran Affairs medical records for review. In the case of Persian Gulf or other veterans, special consideration should be given to wartime duties and experiences including: known or suspected chemical exposures, number of sick bay calls in theater and out, number of times the veteran was ordered to don chemical protective gear, and number of unexplained sightings of dead animals or deceased humans. PHYSICAL EXAMINATION Patients with a history of chemical injury may develop chronic fatigue [behan, 1996; Bell et al, 1998; Buskila, 1999; Dunstan et al, 1995; Heuser, 1993; Tirelli, 1998] (incl. Chronic Fatigue Immune Dysfunction Syndrome (CFIDS), chronic pain (incl. headaches and fibromyalgia), intermittent dizziness and faintness (especially after prolonged standing), and other significant and at times disabling symptoms. A complete history should list all of the above and all additional problems the patient has Go to this link for complete paper http://www.iicph.org/docs/ipph_Defining_Chemical_Injury.htm Quote Link to comment Share on other sites More sharing options...
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