Course Number 18

HANDLING OF ENVIRONMENTAL EXPOSURE CLAIMS

EXPOSED AT WORK? WHO'RE YOU GONNA CALL?

> TYPES OF ENVIRONMENTAL EXPOSURES:
>
> NIOSH, in the 1988 manual entitled "GUIDELINES FOR PROTECTING THE
> SAFETY AND HEALTH OF HEALTH CARE WORKERS" breaks down "exposures" into
> categories, based on the types of "hazard" common to each category.
> They list Chemical Hazards and Physical Hazards. Mutagens and
> teratogens are separately classified, as is Stress, and Dermatological
> Hazards. There is considerable overlap between categories, and very
> little if any guidance is provided for Terrorist Hazards, which might
> be in the form of nuclear, biological or chemical agents.
>
> Using the NIOSH categorization as a jumping off place, I've
> re-categorized these exposure hazards into Radiation Hazards, Chemical
> Hazards, and Biological Hazards. A fourth category, Stress Hazards is
> not covered in this presentation. The final portion of the
> presentation deals with the handling of environmental exposure claims.

I.  RADIATION HAZARDS: In general, we recognize two distinct types of
    radiation hazards -- hazards associated with Ionizing Radiation and
    hazards associated with Non-Ionizing Radiation. Examples of each are
    provided along with brief discussion of target organ systems for
    evaluation, and recommended after-exposure follow-up care and
    monitoring.

    A.  Ionizing Radiation Hazards: Ionizing radiation (IR) is a
        naturally occurring byproduct of the breakdown (decay) of
        radioactive materials. IR is produced anytime an electron is
        dislodged from its parent atom or molecule. IR is artificially
        produced in some types of hospital equipment (I.e. - X-ray
        machines). IR hazards vary in the ability to penetrate the body
        and produce harmful effects. The ability to penetrate the body
        depends on wavelength, frequency and energy of the material.
        Some IR hazards penetrate poorly (E.g. IR Alpha particles),
        while others (E.g. X-rays) penetrate relatively easily.

        1.  Where are IR hazards found in the hospital setting?

-   Diagnostic Radiology

-   Therapeutic Radiology

-   Dermatology

-   Nuclear Medicine (diagnostic and therapeutic)

-   Laboratories (radiopharmaceuticals)

-   Oncology (therapeutic radionuclides)

-   Areas where IR materials are stored or discarded

> 2\. What are the potential Acute adverse health effects of
>
> IR exposure(s)?

-   Humans cannot "sense" any of the forms of IR!

-   Skin reddening (erythema) to "radiodermatitis"

-   Acute Radiation Sickness -- nausea, vomiting, diarrhea, weakness and
    shock

-   NOTE THAT ACUTE EXPOSURES TO IR \>100 ROENTGENS IN A BRIEF TIME
    (MINUTES) IS AN IMMEDIATE DANGER TO LIFE AND HEALTH (IDLH)

-   After a variable time of 2-14 days, fever/malaise

-   Internal and external ulcerations

-   Bloody diarrhea

-   Severe bone marrow depression with attendant S&S

-   If the individual survives for 4-5 weeks, recovery begins, and is
    usually "complete" (long term consequences aside).

-   Very high exposures may produce cerebral edema within minutes and
    death within 24 hours.

-   Important to note that unless the patient has been exposed to
    Neutron radiation, the patient him or herself is not considered to
    be "radioactive".

> 3\. What are the potential chronic health effects of IR
>
> exposure(s)?

-   Remember that IR exposures are cumulative

-   Any IR exposure is assumed to carry some risk -- there is no safe
    level of IR. Bear in mind that the average individual attains a body
    burden of roughly 125 mrem annually just from natural sources of IR.

-   Lung and kidney fibrosis

-   Cataracts

-   Aplastic anemia

-   Sterility

-   Various malignancies (leukemias, bone, skin and thyroid cancers)

-   Premature aging to shortened life span

> 4\. OSHA Standard for IR exposures (29 CFR
>
> 1910.96)

-   Whole body radiation from one exposure not to exceed 3 rem/quarter
    (year)

-   Lifetime (cumulative) exposure not to exceed 5(N-18) rem (Where N=
    age of employee in years and area within parenthesis equals current
    age of individual -- 18. Cumulative exposure limits for a 48 year
    old individual would be 5 times 48-18 or 5 x 30 =150 rem.

-   NOTE: other regulatory agencies exist to cover individuals employed
    by those agencies.

    A.  Non-Ionizing Radiation Hazards: Non-Ionizing Radiation

> lacks the energy of ionizing radiation and causes damage by vibrating
> the atoms or molecules causing heating by friction. Examples of
> Non-Ionizing radiation include Microwave devices, Ultraviolet devices,
> MRI machines, lasers, and other electrical devices, which produce
> electromagnetic fields (EMFs).

1\. What are the potential adverse health effects from non-

> ionizing radiation?

-   Retinal damage

-   Skin damage

-   NOTE: Lasers, which employ voltages often in excess of 15,000 V,
    offer an additional hazard -- electrocution!

2.  Are their OSHA standards for non-ionizing radiation exposures?

    -   Not currently

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II. CHEMICAL HAZARDS: A comprehensive listing of all chemicals covered
    by OSHA, NIOSH, ACGIH and other guidelines is beyond the scope of
    this presentation. Using retrospective analysis of local claims,
    I've summarized the most common chemical exposures dealt with in my
    facility by sub-type.

    A.  ASBESTOS: Asbestos, for this presentation's purposes is fibrous
        magnesium silicate. To be counted in asbestos surveys, fibers
        must be 5 or more micrometers in length with a length to
        diameter ratio of 3:1.

        1.  Where are asbestos fibers found?

-   Fireproof clothing, curtains and roofing

-   Insulation for HVAC system (pre-early 70s)

-   Floor tile/mastic

-   Anywhere fireproof, shockproof, chemically resistant materials are
    needed.

    1.  What are the acute/chronic health effects of asbestos

> exposure?

-   Acute effects are rare -- primarily skin irritation/acute
    respiratory irritation from unfiltered inhalation.

-   Chronic effects typically require a long lag time (phase during
    which the exposed remains asymptomatic) of 15-30 or more years.
    Chronic effects include pneumoconiosis, as well as respiratory and
    more rarely, gastrointestinal malignancies.

-   All asbestos exposed workers have higher than predicted rates of
    lung cancers, however asbestos exposed workers who also smoke are at
    dramatically increased risk for development of lung cancers.

    1.  OSHA Standard for Asbestos Exposures:

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-   Current OSHA permissible exposure limit (PEL) is 200,000 fibers per
    cubic meter (0.2 fibers/cc) over an 8 hr time weighted average (TWA)
    The NIOSH recommended exposure limit (REL) is one half the OSHA PEL
    or 0.1 fiber/cc over an 8 hr TWA.

    A.  CHEMICAL DISINFECTANTS: Many different substances are

> used for chemical disinfection. Typical chemical disinfectants include
> isopropyl alcohol, sodium hypochlorite (chlorine bleach), iodine,
> phenolics, quaternary ammonium compounds, and aldehydes (E.g.
> glutaraldehyde). Glutaraldehyde is used as a type compound. Health
> effects associated with glutaraldehyde exposures may vary
> significantly from other chemical disinfectants. For complete
> information on this category, consult the NIOSH web site (URL
> furnished).

-   Glutaraldehyde is a cold sterilant, used for disinfecting and
    cleaning heat sensitive equipment. It is also used in histology for
    tissue preservation, and as a hardening agent in x-ray film
    processing. It is used in dilutions varying from 1% to 50%. Trade
    names of disinfectants using glutaraldehyde include Cidex®,
    Sonacide®, Sporicidin®, Hospex®, Omnicide®, Metricide®, and
    Wavicide®.

-   Glutaraldehyde exposure can cause respiratory irritation, asthma and
    asthma-like symptoms, nosebleed, eye irritation/conjunctivitis, rash
    (both allergic and irritant dermatitis), staining of exposed skin,
    hives, headache and nausea. (Wow, why do we use this stuff?)

-   NIOSH recommends 10 air exchanges/hr in areas where glutaraldehyde
    is used. Hoods should be used for glutaraldehyde baths.

-   Spills should be cleaned immediately, and open containers should be
    sealed/covered immediately.

-   Latex gloves do not adequately protect vs. glutaraldehyde exposures,
    nitrile or butyl rubber should be used.

-   OSHA and NIOSH do not have standards for glutaraldehyde exposures.
    ACGIH recommends a ceiling limit of 0.2 ppm. A 50% solution of
    glutaraldehyde has a vapor pressure sufficient to produce 20 ppm
    vapor, which is quite sufficient to produce adverse health effects
    in humans.

    A.  ANTINEOPLASTIC DRUGS: Antineoplastic agents derive

> their name from their ability to halt new growths. They are also known
> as cytotoxic agents. Despite their use in cancer therapy, several
> agents are known human carcinogens. Other antineoplastic agents are
> teratogenic (cause fetal mutations/malformations).

1.  What are the acute and chronic effects of exposures to
    antineoplastic agents?

-   Low to absent sperm counts in some exposed males

-   Amenorrhea

-   Fetal death or malformation

-   Adverse effects on bone marrow (suppression), and many other organ
    systems

-   Acute cytotoxicity (Mitomycin-C has reportedly caused loss of
    function of entire hand following accidental needlestick injury to
    digit)

-   Vessication (blistering) (Mustine hydrochloride and doxorubicin)

-   A 1985 study showed correlation between nurses who administered
    antineoplastic therapy, and fetal deaths.

-   Other studies have shown similar health effects in nurses to those
    observed in patients receiving antineoplastic therapy.

    1.  There are no OSHA or NIOSH established limits for

> Exposures. Every exposure should be treated individually, depending on
> route of exposure (respiratory, ingestion, parental, vapors, etc.),
> agent characteristics, and estimated dose received.

A.  ETHYLENE OXIDE: Ethylene oxide is an odorless gas,

> used as a cold sterilant for heat sensitive materials. This agent is
> regulated by OSHA, as it is a known human carcinogen.

1.  This agent is used in Central Supply, Dental Operatories, and
    Surgical Suites.

2.  Acute health effects include: Irritation of eyes and respiratory
    system, skin burns and discoloration of skin, rashes, sores,
    headaches, nausea, and destruction of red blood cells (hemolysis).
    High concentrations can cause vomiting, shortness of breath,
    weakness, confusion, drowsiness, incoordination, cyanosis, and
    respiratory distress leading to death.

3.  Chronic exposure effects include: Reproductive damage in males and
    females, neurotoxicity, and chromosomal abnormalities. A 1981 NIOSH
    study, which is still controversial, found a linkage between
    ethylene oxide (ETO) exposure, and certain leukemias.

4.  Standards include the OSHA PEL of 1 ppm for an 8-hr TWA or 5 ppm for
    any 15-minute exposure period and NIOSH REL of 0.1 ppm for an 8-hr
    TWA or a ceiling limit of 5 ppm for any 10 min exposure period.

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B.  WASTE ANESTHETIC GASSES: This term refers to

> exposures to gaseous anesthetic agents, generally in the form of
> leakage from anesthetic equipment. This leakage is typically due to
> work practices of anesthesia staff, coupled with inadequate scavenging
> (ventilation system problems).

1.  Waste anesthetic gas exposures typically occur in Operating rooms,
    dental operatories, out-patient day-surgery clinics, emergency
    rooms, and labor/delivery/recovery areas in hospitals/clinics.

2.  Acute effects of exposures vary, depending on agent in use, and
    total dose received, and include: Drowsiness, irritability,
    depression, headache, nausea, fatigue, incoordination, and judgment
    errors.

3.  Chronic effects vary with agent, and total exposure and include:
    Fetal toxicity, liver and kidney disease. Some studies have shown
    increased rates of cancer and reproductive pathology (increased
    number of fetal problems with female workers exposed in first
    trimester of pregnancy). Some studies have also shown an increased
    rate of miscarriage in wives of male operating room personnel.

4.  OSHA Standards for the four (4) most commonly employed anesthetic
    gasses are: 2 ppm for a I-hr ceiling for isoflurane, halothane, and
    enflurane, and 25 ppm as a TWA over total exposure period for
    Nitrous Oxide.

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III. BIOLOGICAL HAZARDS:

     A.  BACTERIAL BIOLOGICAL HAZARDS:

         1.  Tuberculosis: (Mycobacteria tuberculosis).

-   Where is Tuberculosis infection risk found in hospitals? (Answer:
    anywhere that air is breathed!) There are numerous documented
    instances of tuberculosis transmission to otherwise healthy
    individuals from a single patient with active disease aboard a
    commercial jetliner. Modern hospital buildings, like commercial
    jetliners, mix "outdoor" air, with circulating air. The greater the
    fresh air mix, the lower the risk of disease transmission for any
    biological agent.

-   The greatest risk in healthcare settings is from the unsuspected
    positive TB patient. We take routine precautions for individuals
    suspicious for active tuberculosis.

-   In the years between 1963 and 1985 new cases of tuberculosis
    declined every year. Since 1986, there has been a general increase
    in the number of new cases diagnosed each year. Presumably, this is
    at least in part due to the effect of HIV and AIDS.

    1.  Anthrax: This is added new this year secondary to the exposures,
        illnesses and death from Anthrax following the September 11,
        2001 terrorist activities. The bacterium is transmitted either
        in pus secretions, or via airborne particles (deliberate or via
        cough aerosol). The infected person is considered infectious for
        the entire duration of the illness.

    2.  Common Bacterial Conjunctivitis: The bacterium responsible for
        the illness is directly transmitted thru drainage and
        secretions. The infected person is considered infectious for the
        entire duration of the illness.

    3.  Legionairre's disease: Causative agent, Legionella pneumonia, is
        thought to be spread by respiratory (nasal?) secretions. Note
        that the aquifers in many old cities are colonized by Legionella
        species. Spread thought to be expedited by water-tower cooling
        systems, which can aerosolize huge numbers of organisms into
        room air. Shower heads and faucets have also been implicated in
        disease transmission. Duration of infectivity is not clear at
        this time.

    4.  Bacterial meningitis: Newborns and immunocompromised are
        primarily at risk. Feces may be the vehicle, which spreads the
        infection.

    5.  Meningococcal pneumonia: Spread by respiratory secretions.
        Infected individuals are considered infectious for a minimum of
        24 hours after treatment has been initiated.

    6.  Plague: Possible bioterrorism weapon. Infectious agent is
        Yersinia pestis. The organism is endemic in several Western
        states (California, Arizona, Nevada and New Mexico) where it
        infects wild rodents. Transmission is via contact with infected
        animals, or by flea bites from infected animals. Infected humans
        may transmit the disease via secretions or pus, and rarely by
        cough aerosol. Patients are considered infectious for a minimum
        of three days following initiation of antibiotic therapy.

    7.  Tularemia: Possible bioterrorism weapon. Infectious agent is
        Francisella tularensis. The organism is spread by
        drainage/secretions and pus. Infectivity is thought to persist
        for the duration of the illness.

    8.  Superinfection (infection with resistant organisms) -- E.g.
        Methicillin resistant Staphylococcus aureus (MRSA) or Vancomycin
        resistant enterococcus (VRE). There are many questions
        unanswered about these and similar resistant organisms.
        Antibiotic sensitivity, in general, is waning, largely due to
        indiscriminate use by clinicians, with contributions from the
        agricultural industry. In general, we humans are already quite
        thoroughly colonized with the more prosaic Staphylococcus
        aureus, and numerous species of enterococcus. There is little
        reason to postulate that a resistant organism will jump from the
        patient to the healthcare worker. Colonized healthcare workers,
        on the other hand, have been implicated in nosicomial outbreaks
        of resistant organisms primarily through poor sterile technique.

> B. VIRAL BIOLOGICAL HAZARDS:

1.  Human bloodborne pathogens: Hepatitis B and C,

> and HIV.

-   Exposure via contact with blood or bloody fluids, either
    parenterally, or via splash to non-intact skin or mucous membranes,
    rarely by contact with viral cultures in virology research labs.
    Non-work related exposures include sharing of IV needles in IV Drug
    abusers, and sexual contact.

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-   Post exposure prophylaxis (PEP) for the bloodborne pathogens is via
    protocol.

-   Hepatitis B is preventable through HB vaccination.

-   Although we focus primarily on the three viral bloodborne diseases
    listed above, other examples of bloodborne viral diseases exist.
    These include: Arthropod borne viral diseases (dengue, yellow fever,
    lyme disease, and Colorado tick fever), Babesiosis, Creutzfeld-Jakob
    disease, Leptospirosis, Malaria, Rat-bite fever, Relapsing fever,
    Syphilis, and the Viral Hemorrhagic Fevers (Crimean-Congo fever,
    Lassa fever, Marburg viral fever, and Ebola fever).

2.  Chickenpox (varicella): Causative agent is the

> Varicella virus. The virus is spread by respiratory secretions (cough
> aerosol), as well as by fluid from lesions. The individual is
> considered to be infectious until all lesions are crusted over.

3.  Viral conjunctivitis (pink eye): The causative agent is

> a virus, typically in the Adenovirus family. The virus is spread by
> secretions and purulent exudates. The individual is considered
> infectious for the duration of the illness.

4.  Rubella (German measles): Causative agent is a

> Togavirus (likes to party?). The virus is spread by respiratory
> secretions (cough aerosol). The individual is considered infectious
> for a minimum of seven (7) days after onset of rash.

5.  Hepatitis A (infectious hepatitis): Although this virus

> has reportedly been transmitted by blood, this is a distinctly
> uncommon route. Typically, the virus is spread from fomites (feces or
> fecal contaminated materials). The individual is considered to be
> infectious for a minimum of seven days following onset of jaundice.

6.  Herpes simplex: The causative agent is the

> Herpesvirus hominis. The disease is spread via drainage or secretions
> and from fluid within vesicles. The individual is considered to be
> infectious for the duration of the illness. This disease can cause
> severe illness and death in immunocompromised individuals.

7.  Herpes zoster (Varicella-Zoster virus). See varicella.

8.  Influenza: Infectious agent is an orthomyxovirus

> Which is transmitted by respiratory secretions and cough aerosol. The
> person is considered to be infectious for the duration of the illness.
> Annual fall "Influenza vaccination campaigns" help prevent epidemic
> flu, but are less than fully effective unless the target population
> achieves "herd immunity", which requires a minimum of 50% of the
> target population to be vaccinated.

9.  Rubeola (measles): The infectious agent is a

> Paramyxovirus. The virus is spread by respiratory secretions and cough
> aerosol. The individual is considered to be infectious for a minimum
> of four days following onset of rash.

\` 10. Mumps (infectious parotitis): The infectious is a

Paramyxovirus. The virus is spread by respiratory

secretions. The individual is considered to be

infectious for a minimum of nine days following

swelling of glands.

> 11\. Rabies: Infectious agent is a rhabdovirus, which is
>
> transmitted by infected saliva, typically into a bite
>
> inflicted by the animal. The condition is essentially
>
> universally fatal once symptoms begin. The
>
> incubation period is long -- one week to years, but
>
> generally is 307 weeks. The individual is considered
>
> infectious once symptoms begin, and handling of the
>
> cadaver requires special precautions.

12. Smallpox (variola): Possible bioterrorism weapon. The infectious
    agent is the Variola virus, which is spread by respiratory
    secretions and fluid from lesions. The individual is considered to
    be infectious for the duration of the illness.

> IV: VAGUE ENVIRONMENTAL ILLNESS CLAIMS: Environmental
>
> Medicine is a controversial title to most clinicians. Proponents
>
> warn that we are all slowly being poisoned by extremely toxic
>
> petrochemicals, released into our environment. A number of
>
> equally controversial diagnoses have been suggested, including,
>
> but not limited to: Multiple Chemical Sensitivity, Chronic
>
> Fatigue syndrome, Fibromyalgia, Chronic Neuroimmune
>
> Diseases, and Sick Building Syndrome.
>
> A line excerpted from a Web site hosting discussions of
>
> Environmental Illnesses reads: "All meetings are fragrance free
>
> and wheelchair accessible. Please respect others and refrain
>
> from wearing fragrances, fragranced hair and other products,
>
> and clothing scented by detergents, fabric softener, and dry
>
> cleaning chemicals. Newspapers should be left at the door."
>
> With apologies to the "true believers", I suggest that common
>
> sense also be left at the door!
>
> It is beyond the scope of this presentation to debunk the half-
>
> truths, and just plain bad science, thrown about by advocates
>
> of environmental illness. I will address Sick Building Syndrome.

WHAT IS SICK BUILDING SYNDROME (SBS)?

-   An excess of work related irritations of the skin and mucous
    membranes and other symptoms, including headache, fatigue, and
    difficulty concentrating, reported by workers in modern office
    buildings.

-   Symptoms include: burning/watering eyes and nose, hoarseness, cough,
    sore throat, headaches, shortness of breath with mild exertion,
    debilitating muscle and joint pain, chronic fatigue, dry/itchy skin,
    dizziness, nosebleeds, difficulty concentrating, and absence of
    symptoms when away from building/area.

-   Proposed etiologies include: chemical contaminants from indoor
    sources (adhesive outgassing, carpets, manufactured wood products,
    copy machines and printers, cleaning agents, pesticides, and
    products of combustion(s) (POCs), pesticides and fumes from poorly
    ventilated plumbing or lab exhaust hoods, biological contaminants
    (bacteria/pollen, molds/fungi/insect, bird or other pest droppings,
    dust mites, and finally psychological contaminants (whatever that
    means).

-   By definition, in SBS, cause is unclear.

-   PLEASE NOTE THAT THERE IS A SECOND, NON-SPECIFIC CLASSIFICATION
    WHICH APPEARS TO BE TOTALLY UNRELATED TO SICK BUILDING SYNDROME --
    THIS IS KNOWN AS "BUILDING RELATED ILLNESSES" OR BRIs. A BRI is (by
    definition), "a diagnosed condition occurring in an individual or
    group of individuals, causally related to locale". In other words,
    by definition, BRI has a clear-cut cause. An example of a BRI is
    Legionairre's Disease. The locale, for the initial outbreak, which
    gave the name to the disease, was a hotel, which hosted a convention
    of members of the American Legion. Eventually, the disease
    (pneumonia secondary to Legionella organisms) was tracked to the
    hotel's water-cooling towers. By definition, if there is a known
    cause and a known diagnosis, the condition is properly termed a BRI.
    The corollary is that undiagnosed conditions with uncertain causes
    are, by definition SBS cases.

-   Anyone familiar with "Gulf War Syndrome" will immediately recognize
    the symptoms associated with SBS. This raises the question -- were
    our troops deliberately or accidentally exposed to agents, which
    produced the symptomatology?

-   I believe Thomas Occam, the 14^th^ Century philosopher said it best.
    "The mind should not multiply entities without necessity. What can
    be done with fewer...is done in vain with more" (or more simply
    stated -- the simplest explanation is generally correct).

-   Plain, old, garden-variety depression causes somatization, which is,
    essentially, preoccupation with one's body and bodily functions.
    This, per Occam's Razor is the most likely explanation for the
    myriad of complaints loosely aggregated into Sick Building Syndrome
    (or Gulf War Syndrome, for that matter).

> V: HANDLING OF ENVIRONMENTAL EXPOSURE CLAIMS:
>
> A. CA-1 CLAIMS:

-   Time frame during which symptoms develop is the key to a proper CA-1
    claim. Virtually all SBS claims, and the overwhelming majority of
    Environmental Illness-type claims do not meet the criteria for
    filing as a CA-1.

-   Many, but not all "exposure" claims DO qualify for filing as a CA-1.
    Again, the time frame during which the symptoms develop will lead to
    the correct claim form. If the condition develops over a period of
    time greater than one shift or one day, it will not be accepted as
    an Occupational Injury

-   NOTE: THAT THE CA-810 PUBLICATION CAUTIONS AGAINST FILING CLAIMS
    ASSOCIATED WITH SIMPLE EXPOSURE TO AN INFECTIOUS DISEASE WITHOUT THE
    OCCURRENCE OF A WORK-RELATED INJURY. "*[BOTH A WORK-RELATED INJURY
    AND EXPOSURE TO A KNOWN CARRIER MUST OCCUR BEFORE OWCP CAN PAY FOR
    DIAGNOSTIC TESTING."]{.underline}*

-   Within these guidelines, if the exposure event is documented to have
    occurred at a specific point in time, and it can be documented that
    the individual was exposed to a communicable disease, the CA-1 form
    is the appropriate form.

> 2\. CA-2 CLAIMS:

-   Virtually every "Environmental Illness-type" claim should be filed
    using the CA-2 form. The criteria for filing of a CA-2 is "An
    Occupational Disease is a condition produced in the work environment
    over a period longer than one workday or shift. It may result from
    systemic infection, repeated stress or strain, exposure to toxins,
    poisons or fumes, or other continuing conditions of the work
    environment."

-   The employee should not be seen or treated as an employee. To do
    this would remove one of the primary disincentives for filing a CA-2
    claim. All employees filing CA-2 claims are required to put
    something at risk (their healthcare dollars, and their sick or
    annual leave).

-   I have seen DOL opinions, siding for CA-2 claimants who received
    care as an employee. The reasoning was that the Agency must have
    already decided that the employee's claim was valid or they would
    not have offered to diagnose and treat the condition.

"It helps to use your head rather than your heart in handling many
Environmental Exposure or Environmental Illness claims."

Ronald C. Hamm, M.D.

Chief, Administrative Medicine Section (WLA)

Greater Los Angeles VA Healthcare System

\(310\) 268-3522

ronald.hamm@med.va.gov