Indian Health Service Rotation

Report
Indian Health Service
Rotation
Natalie Branagan
August 28th, 2007
HPI
► 72
yo man referred to the Radiation
Exposure Screening and Education Program
clinic for positive review of systems on
hospital screening – reported shortness of
breath and has a history of working in the
uranium mines.
HPI
► The
patient reports that he has had
shortness of breath beginning about 9
months ago.
► Unable to walk greater then 50 feet.
► No orthopnea, no lower extremity edema
► Reports occasional chest pain
► No cough, no fevers or chills
HPI
► Worked
in two uranium mines from 1958 – 1959
 Worked underground and above ground dumping
mining waste material
 Sometimes wore a mask
 Stopped mining after falling at work – sustained a
fracture to right arm and hit his head
 Recounts how electricity was lost for approximately one
hour while working in mines once – mechanical
ventilator and elevators stopped working during that
time.
Past medical history
► Coronary
artery disease
 Status post CABG 11/06
► Hypertension
► CVA
in 10/06
 Residual left sided hemianopsia and difficulty
speaking clearly
► Bilateral
carotid bruits diagnosed 2000
 Refused workup at that time
Medications
► Aspirin
325 mg daily
► Atenolol 25 mg daily
► Multivitamin
► Allergies:
NKDA
Family history
► Mother
and father deceased of unknown
causes in their 80’s
► No known family history of hypertension,
diabetes, CVA or myocardial infarction
Social history
► Lives
with wife
► Retired currently
► Worked as a bus driver after working in
mines up until about 1 year ago
► Owns sheep and cattle
► Denies smoking, alcohol or drug use
Review of systems
► Reports
unable to see out of left eye since
CVA
► Also reports difficulty with memory ever
since falling and hitting head in the mines
► Occasional palpitations
► No abdominal pain, nausea, vomiting,
dysuria
Physical exam
►
►
►
►
►
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Vitals: T 98.0, P 82, BP 164/96, RR 16, 94% on room air, weight 77.7
kg, height 65 inches
Gen: elderly appearing Native American man in no acute distress
HEENT: PERRL, mucus membranes moist, no lesions
Neck: no jugular venous distention, no cervical nodes
c/v: regular rate and rhythm, normal s1 and s2, no murmurs, rubs or
gallups
Pulm: fine crackles at bases bilaterally, no dullness to percussion
Abd: soft, not tender, not distended, no hepatosplenomegaly,
normoactive bowel sounds
Extremities: no cyanosis, clubbing or edema, 2+ peripheral pulses
Labs and studies
► ABG
21%
► PFTs








7.42/34/51/-1.6/21.7/85.4% with FI02 of
FVC 3.72 Liters (54%)
FEV1 2.89 Liters (61%)
FEV1/FVC 0.78 (113%)
FEF 25% 6.50 (91%)
FEF 75% 1.02 L (100%)
FEF 25-75% 2.77 (86%)
FEF max 7.07 89%
Hgb 15.7 g/dL
Chest x-ray
► s/p
CABG, slight cardiomegaly, pulmonary
vasculature normal, no infiltrate or pleural
effusion, degenerative changes in the spine
Uranium mining and the
Navajo experience
Uranium
► Found
at low concentrations naturally in
soil, round, surface water and ground water
► Radioactive
► Several isotopes, however U238 is
predominant isotope in naturally occurring
uranium
► Half-life of U238 is 4.5 billion years
Uranium
► Primary
use is as fuel in nuclear power
reactors to make electricity
► Highly enriched uranium is a component of
nuclear weapons
► Uranium ore is usually found in hard rock or
sandstone
Uranium mining history
► 1948
the US Atomic Energy Commission
began to purchase all uranium mined in the
US
► Uranium mining became a large industry in
Utah, Arizona, New Mexico and Colorado
► Uranium mining peaked in the 1950’s with
over 750 mines operating
► Approximately 3,000 uranium miners were
Navajo
Uranium mines on Navajo land
Uranium demand increasing
Western World Uranium Production and Demand 1945-2004
www.uic.com
Uranium mining
► Underground
mining
 Involves drilling of shafts into sandstone,
blasting, loading ore into bins and transporting
ore up via elevators
 Miners were exposed to large amounts of dust
and smoke after re-entering the mines after
blasting
Brugge, D. Am J Public Health 2002;92:1410-1419
Uranium mining and milling
► Uranium
ore contains between 0.5 -2% of
uranium oxide
► Milling is the process in which uranium
oxide is extracted from the uranium ore
 Involves crushing the mined ore, mixing it with
water and adding chemicals such as sulfuric
acid to separate out of the uranium ore, the
liquid is then filtered from the rest of the
material, and is concentrated by precipitation
and then dried.
Health effects of uranium mining
► Degenerative
joint disease
 From repetitive motion
► Trauma
 As result of crush injuries from heavy equipment or
falling rock
► Hearing
impairment
 From drilling and blasting
► Diseases
of the lungs
 Exposure to dusts, fumes and gases can cause
malignant and nonmalignant diseases
Mulloy, K et. al. Environmental Health Perspectives 2001;305-309
Nonmalignant lung processes
► Pneumoconiosis
 Lung diseases caused by the inhalation of dust
► Silicosis
 Pulmonary diseases caused by the inhalation of silica
► Diffuse
fibrotic lung disease
► Pulmonary fibrosis
► Obstructive lung disease
► Tuberculosis
Mulloy, K et. al. Environmental Health Perspectives 2001;305-309
Malignant lung processes
► Carcinogens
lung cancer
suspected or known to cause
 Arsenic, silica dust, diesel exhaust, radon
Radon
► Radon
exposure poses one of the greatest
risk for developing lung cancer among the
other exposures listed previously
► Clear odorless gas
► Produced from breakdown of uranium
► Causes production of radon daughters which
emit alpha particles
► Exposure to alpha particles cause mutations
in DNA
www.lungusa.org
Radon
► Exposure
to radon measured in working
level months (WLM)
► A working level is 130,000 MeV of potential
alpha energy that is released from an
amount of radon decay product in one liter
of air
► 1 working level month is one working level
exposure for a period of 170 hours (average
number of hours a miner would work)
www.ma.utexas.edu
WLM
► In
an average home
 Annual WLM is 0.2
 Lifetime exposure 10-20 WLM
► In
one study of Colorado Plateau
underground uranium miners working
before 1974
 WLM ranged between 465 to 16,467
Mulloy, K et. al. Environmental Health Perspectives 2001;305-309
Lung cancer attributed to radon
exposure in uranium mining
► Estimated
that ~ 70% of all lung cancer
deaths in nonsmoking miners are due to
exposure to radon daughters
► Approximately 40% of all lung cancer
deaths in smoking miners are due to
exposure to radon daughters
Lubin JH, et al. J Natl Cancer Inst 1995 87:817-27.
Mechanism of action of damage to
lung
► Radon
daughters are inhaled with mine dust
► Alpha particles that pass through cell nuclei induce
damage to DNA
► Radiation damages cell membranes and blood
vessels
► Alpha particles cause water molecules to
dissociate into free radicals which interact with
biological molecules
► Radiation causes a disruption in collagen
metabolism
Archer V, et al. JOEM 1998;40:460-74.
Compensation
► Radiation
(RECA)
Exposure Compensation Program
 Enacted in 1990
 Purpose: to provide compensation for people
who developed particular cancers or diseases
related to exposure to radiation from either
working in the uranium mining industry or
exposed via above ground nuclear weapon
testing
Compensation for miners
►
►
►
Must have worked for at least one year or been exposed to 40 or more
working level months (WLMs) of radiation in above or underground
uranium mines in Arizona, Colorado, New Mexico, Wyoming, South
Dakota, Washington, Idaho, North Dakota, Oregon, Texas, or Utah
between 1942 and 1971.
AND
Must have developed at least one of these diseases




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►
Primary cancer of the lung, trachea or bronchus
One of the following nonmalignant respiratory diseases
Pulmonary fibrosis or fibrosis of the lung
Cor pulmonale related to fibrosis of the lung
Silicosis
Pneumoconiosis
Payment amount: $100,000
www.bu.edu/formerworker
Compensation for millers
►
►
►
1) Must have worked for at least one year in a uranium mill or
transporting uranium ore or vanadium-uranium ore from mines or mills
located in Arizona, Colorado, New Mexico, Wyoming, South Dakota,
Washington, Idaho, North Dakota, Oregon, Texas, or Utah between
1942 and 1971.
AND
Must have developed at least one of these diseases
 Primary cancer of the lung, trachea or bronchus
 Renal cancer or other chronic renal diseases, including nephritis and kidney
tubal tissue injury
 One of the following nonmalignant respiratory diseases
►
►
►
►
►
Pulmonary fibrosis or fibrosis of the lung
Cor pulmonale related to fibrosis of the lung
Silicosis
Pneumoconiosis
Payment amount: $100,000
www.bu.edu/formerworker
RESEP
► The
Radiation Exposure Screening and Education
Program
 sponsored by the U.S. Department of Health and
Human Services Division of Primary Health Care
 Came about as a result of the RECA amendment of
2002
► “it
should be the responsibility of Federal Government in
partnership with State and local governments and appropriate
healthcare organizations, to initiate and support programs
designed for the early detection, prevention and education on
radiogenic diseases”
http://books.nap.edu
RESEP screening services
► Health
screening
 History, physical exam, obtaining appropriate medical
tests
► Education
 Detection and prevention of disease linked to exposure
to radiation
► Referral
 for treatment
► RECA
counseling
 Help with compensation claims
RESEP Screening protocols
► History
 must include date of exposure, place, duration of
employment and tobacco use
► Physical
exam
 emphasis on pulmonary, cardiac and renal exam
► Chest
radiography
 standard posterior-anterior view chest radiograph for
presence of radiologic fibrosis, silicosis or
pneumoconiosis
► Pulmonary
Function testing
 as needed including spirometry, lung volumes, arterial
blood gases and a DLCO
Eligible for compensation
► Nonmalignant
disease
 Biopsy or chest imaging documentation
 Chest x-rays are interpreted by two readers
 spirometry
► FEV1
< 80% or FVC < 80%
 ABG
► pCO2
30 mmHG and pO2 < 70 for an altitude of > 3,000 feet or
pO2 < 75 for an altitude < 3,000 feet
► Malignant
disease
 Written documentation
Mulloy, K. Environmental Health Perspectives 2001;109:305-9
Case
►
►
►
CXR s/p CABG, slight cardiomegaly, pulmonary vasculature
normal, no infiltrate or pleural effusion, degenerative
changes in the spine
ABG 7.42/34/51/-1.6/21.7/85.4% with FI02 of 21%
PFTs





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FVC 3.72 Liters (54%)
FEV1 2.89 Liters (61%)
FEV1/FVC 0.78 (113%)
FEF 25% 6.50 (91%)
FEF 75% 1.02 L (100%)
FEF 25-75% 2.77 (86%)
FEF max 7.07 89%
Hgb 15.7 g/dL
RESEP screening protocol
► If
an abnormality is noted with the initial
screening then further testing is waranted.
 Includes high-resolution CT scans,
bronchoscopy, V/Q scans, pulmonary
angiography and thoracentesis, pleural bx, MRI
and PET scanning, 24 hour urine testing, renal
ultrasound, tissue biopsy or aspiration,
endoscopy
RESEP follow up
► Follow
up for nonmalignant cases includes
periodic re-evaluation
► Follow up for malignant cases includes
involving a case manager to help facilitate
the process of documentation and follow up
Compensation
► Amount
of compensation $100,000
► Difficulties encountered with compensation
claims
 Often times it is difficult to document exposure
to radon
 Access to diagnostic resources can be difficult
 Difficult to recognize the diseases
Mulloy, K. Environmental Health Perspectives 2001;109:305-9
Prevention
► Clean
Air Act
 Maximum uranium dose is 10 millirem from the air
► Sets
standards for site clean-up
 A person’s risk for developing cancer must not be increased to
greater than 1 in 10,000
► Safe
Drinking Water Act
 Limits contamination of water from uranium to no more
than 30 micrograms per liter of water
► Uranium
Mill Tailings Radiation Act
 Directs the EPA to set standards for clean up and
disposal of contaminants
► Limits
air emissions and soil and groundwater contamination
www.epa.gov
References
►
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Assessment of the scientific information for the radiation exposure and screening and
education program 2005. Accessed on 12/16/07 at
http://books.nap.edu/openbook.php?record_id=11279&page=10
Archer V, Renzetti A, Doggett R, et al. Chronic diffuse interstitial fibrosis of the lung in
uranium miners. JOEM 1998;40:460-74.
Brugge D, Goble R. The history of uranium mining and the Navajo people. Am J Public
Health 2002;92:1410-1419.
Gilliland F, Hunt WC, Pardilla M, et. al. Uranium mining and lung cancer experience
among Navajo men in Arizona and New Mexico, 1969 to 1993. J Occup Environ Med
2000;42:278-83
Lubin JH, Boice JD, Edling C, et al. Lung cancer in radon-exposed miners and the
estimate of risk from indoor exposure. J Natl Cancer Inst 1995 87:817-27.
Mulloy K, James D, Mohs K, et. al. Lung cancer in a nonsmoking underground uranium
miner. Environmental Health Perspectives 2001;305-309
Radiation exposure compensation program. June 2006, accessed on 12/16/07 at
http://www.bu.edu/formerworker/RECP_Factsheet.pdf
Uranium. Human Health Factsheet. August 2005, accessed on 12/15/07 at
http://www.ead.anl.gov/pub/doc/Uranium.pdf
World Uranium Mining Nuclear Issues Briefing Paper 41 accessed on 12/15/07 at
http://www.uic.com.au/nip41.htm

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