00:00:06,019 --> 00:00:08,297 Good afternoon . Thank you for joining . I'm Doctor Lolita o'donnell , the academic superintendent and the director of the continuing education program office here at the J seven . You may be wondering why we hold special feature , webinars . Special feature webinars allows the DH AJ Seven education and training directorate to collaborate with the defense health agencies , subject matter , experts in the fields of medicine , research and education within the military and other partner agencies to include the va to bring the state of the science education and training to our health care providers that attend these events . We wanted to highlight today's important topic in order to fully support the mission of the H A by providing a medical benefit , commensurate with the service and sacrifices of more than 9.6 million active duty personnel , military retirees and their families . I would like to introduce Colonel Dian Stroll who will provide opening remarks for today's event . Colonel Stu is the Director of Education and Training at the Defense Health Agency headquarters here in Falls Church , Virginia . In this role , she directs the joint development and sustainment of the Department of Defense medical Training initiatives and education and training policy . Leading 130 personnel across four geographical regions . She's directly responsible for 38 professional development , medical readiness and regulatory programs , training for over 3500 Department of Defense and international students annually . Thank you again for attending . I will now turn the event over to Colonel Strobel . Thank you . Good afternoon . The Defense Health Agency J seven education training directors , continuing education program office or CPO welcomes all of you to our special feature webinar . Before we begin , let us review some event details . There may be a visual delay as we advance the slides in the presentation . Please be patient as the connection catches up with the speaker's comments . The theme of today's event is environmental exposures including discussion about the airborne hazards and open burn pit registry , associated medical evaluations and the individual longitudinal exposure record . The Department of Veterans Affairs developed the airborne hazards and open burn pit registry to help service members and veterans document potential exposure to airborne hazards in deployed settings . The presenters who are speaking today have been involved over the years in sharing some wonderful resources with our military health care providers . Regarding environmental exposures . Today's discussion delves further into the support services available for service members and veterans who have military exposure concerns through research , health care benefits , transition support , outreach and education . I would now like to introduce the presenters for today's event . Mr Stephen Jones is a retired army environmental Science and engineering officer and senior consultant with over 31 years of medical , public health and environmental health experience at all levels of the Department of Defense . We also have Doctor Eric Xing . He currently serves as the operations director with health outcomes of military exposures in the Department of Veterans Affairs . He came to the Veterans Health Administration after retiring from 27 years of service in the army . Doctor Mossy works as a federal civilian physician in occupational and environmental medicine for Defense Centers for Public Health Aberdeen , formerly known as Army of Public Health Center . He completed residencies and family practice , occupational and environmental medicine , general preventative medicine , and public health and aerospace medicine . He has three master's degree in industrial hygiene , epidemiology and environmental toxicology . Finally , I'd like to introduce Mr Larry Van Der Graff . He served as a project controller for the joint dod va individual longitudinal exposure record or I and is responsible for the day to day development activity and engagement with key stakeholders . Welcome Mr Jones , Doctor Doctor Monastery and Mr Van Der Graff . We are honored for your participation in today's events . Thank you . Thanks uh for the introduction . And uh we welcome the opportunity to be speaking to a very large audience , uh and very talented audience . No doubt about a topic of utmost interest and concern I E environmental exposures . So our um and we look forward to your comments and questions . I know the questions will be via the chat , but that's the way it works . So we look forward to your questions as the each presenter presents . And then at the end , we'll have a panel discussion and open discussion on all , all the topics presented . Uh go to the next slide , Brian . Uh This is the , I guess on the disclosure piece , uh all the presenters today have no relevant financial or non-financial relationships to disclose and that applies to all of us next slide , please . Ok . Uh Learning objectives . Uh This is what we hope to put out today . Uh I think we've got a , a good list of speakers , good topics . So we're confident obviously that we will achieve these learning objectives . I'll start , I'll start it off with uh common examples of environmental exposures of concern . I'll be followed by doctor Eric Ching who will provide an overview of the airborne hazards and open burn pit registry . He will be followed by Doctor Jesse Monsters , uh who will explain the role of health care providers in conducting medical evaluations associated with environmental exposure concerns . Then I'll come back in with Mr Vander Grip and I'll provide a few opening remarks about the individual longitudinal exposure record and then Larry will do a live demo of that uh of the island . And I think you'll be very impressed with that demo as to what functionality we have now and live functionality if I may say with the island next slide , please . So as far as environmental exposure is of concern . Um The scope of this is there's a couple of things missing . There . One is training . So this is , this is not just about deployments and burn pits , which obviously that's very important . Um This , this encompasses wherever the troops may be , be , whether it's garrison a workplace uh out at the training environment or at contingency locations during a deployment . And you can see uh some pictures there of the list of exposures of concern we've had over many years , whether it's the uh oil well fires and desert shield , desert storm agent orange in Vietnam , other radiation exposures in the training event . And you can see uh we also have significant concerns when our troops are deployed in mega cities that have obviously a pre uh many , many um uh exposures of concerns in those mega cities that picture in the far right up there is a , that's the garrison training and that's a shootout . So that's where uh the troops go in and do live fire . And of course , uh the exposure to the lead from the , the weapons that they fired . That's of concern , burnt pits , naturally occurring exposures like the big dust storms there in uh during Southwest Asia , the , the uh operation in Southwest Asia followed by subterranean exposures . There's uh troops that are , that are training , deploying within uh subterranean structures such as uh uh metros very concerned and day to day workplace environments . There's multiple workshops on multiple installations where our troops and the civilians that support them , they're in there doing their job and there's potential exposures based on what that job entails . And then down , finally , down below uh the industrial complexes that we may be uh deployed near uh a , a variety of the exposure , potential exposures from those , those particular areas . So again , it's a garrison training and deployment and what's not shown here that I could easily show is also at home . I mean , there's , there's exposures to the troops at home as well . Veterans at home as well , depends on what they , they do as a hobby . Let's say there might be some exposures that they would incur at home as well . So it's our concern is the totality of the exposures that may occur to a service member or veteran and then taking appropriate action is necessary . Next slide , please . So , uh , what we're gonna do here in the next three slides , I'm not gonna , uh , hopefully , uh , it , we'll get through this , but there's a , there's a plethora of congressional and White House I E executive requirements that have been put out . And this , the next couple of slides is a list of some of those of the most important ones that are driving what we have been doing and what we will continue to do . Uh going all the way back to 1986 the veterans benefits to establish the Ionizing Radiation Registry . And that's generally because of events that occurred in the past . So now we need to establish an ionizing radiation registry to track those veterans . The outcome of the , the veterans look for any potential medical conditions and treat accordingly . And then jumping up to 91 Agent Orange Act . I'm sure you're all familiar with that post Vietnam with establishing the presumption of service connection to certain illnesses based on their , their deployment to um uh Vietnam and other places where Agent Orange was known to be uh moving on to 92 the Veterans Health Care Act , uh another registry . So this is Post Desert Shield , Desert Storm , I E the Gulf War and we were required to the veteran . The VA was required to set up a Gulf War registry , which of course they did and I'll show you uh where we're connect to these registries with our individual longitudinal exposure record . Once we get to that part of the presentation today , I'll show you how we all these registries that have stood up . They have information about exposures on the individual level . So it's important that we pull from those registries to populate that respective uh service member or veterans Isler in a medical tracking system . There was , um that's , that was back in , um , you see that was back in the 1997 and that's where we first started . It's getting congressional direction to set up pre deployment exams , post deployment exams and maintain uh a centralized record of these exams . That's where you start seeing uh again , periodic health assessments , post deployment , health assessments , post deployment , health reassessments , separation , health assessments , all associated with uh these , these previous laws . Uh 1997 the uh N D A A 1998 established a medical tracking system for deployed service members . Um Then the , the big one there is the PR D five presidential regime . Number five , create a new Force health Protection program , lifelong medical record of all illnesses and injuries care and inoculations and exposures to different hazards . So this to me , that's the fundamental uh starting point in , in terms of developing the is , is this pr D number five , very important and that was , that was post uh post uh deployments and wars in Iraq as well . Uh January 23 is the um or January 2013 , excuse me , uh the va was directed to establish the airborne hazards and open burn pit registry and doctor chopping will give you a a good overview of that . Uh Next slide , please . Moving on to uh January two th 2013 . Uh So everything I just talked about was almost associated with the contingency environment or wartime environment . Now you start , I'll just uh put out some that shows we have to issue the guidance to take care of the environmental exposures on military installations as well . And in this particular one is when would we request that the agency for toxic substances and disease registry , I E A T S D R . When would we expect them to come in ? What's the criteria for requesting that they come in and do a public health assessment based on a potential or known contamination on a military installation ? Uh December 2017 , uh declassification of documents . And that's important because if these documents remain classified , we will not be able to extract that information and upload it to the individual longitudinal exposure record . So if it , if the declassification laws uh or boundaries allow it , the more we can declassify of known incidents where there was an exposure , the more we can populate a veterans uh or service members record . Then another one on housing is a process to uh record and resolve environmental health houses and housing . And those types of hazards could range from lead asbestos , mold radon . All of these could be present in housing . And there's a big push over the last three or four years to identify those uh hazards and clean them up , obviously mitigate so that the the living environment could be safer . A lot of work in that area by , by those folks who run the housing on the installations . And then in uh a big one in August of 2022 the sergeant , first class , first class Heath Robinson , honoring our promise to address Comprehensive Toxics Act . So the uh Pact Act and , and that was very comprehensive . I'm sure you all know about that uh provisions to address health care , presumption of service , connections , research resourcing and exposure , data and records for veterans and service members . So , a very comprehensive Act and we are working closely dod and va working very closely to enact the Pact Act because there's a lot of requirements in there and dod s got a lot of support requirements in there as well to provide to the VA and then uh December 2022 . Uh that's the latest N D A A that came out in this uh N D A A 2023 . There's a big one in there . It's called section seven oh four . And that requires us to do a capability assessment . I , what's our capability to assess these environmental exposures that I that I just talked about ? All right , and what I would identify the gaps and then identify and provide an action plan where you're going to address those gaps that you , that you assessed so that we can improve our ability to assess the environmental exposures , to mitigate those exposures and to inform health care research and everything else associated with those exposures . Next slide , please . And this is the honor . Uh again the Sergeant first class Heath Robinson Pact Act . Uh There's several provisions in there , uh focusing on one on section eight oh two , the Bionic briefing of the Isler , that means every two years , we have to provide a briefing to the , the congressional members on the Isler and focusing on the quality of the data in the Isler because that's key if the the data has to be of good quality in order for it to be used to present an exposure summary for that individual . Therefore , to inform either the health care encounter , the epi research , the health effects research claims uh adjudication , disability adjudication . So we have to have good quality data to inform those uh targeted users and then the overall usefulness of the island . That's all that's going to be part of our briefing to the congressional members as well . Then there's five sections there in terms of supporting uh supporting the va with establishing Presumptions of service connection based on toxic exposures . Uh part of an inter-agency working group that's going to focus on toxic exposure research analysis relating to mortality of veterans who served in Southwest Asia . Again , we will , we will support the va as they take the lead on on these particular sections . And then a big one here is section eight oh three , correction of exposure records by members of the armed forces and uh and veterans . Meaning here's your Isler . We're gonna give you access to your Isler , you go in there and look at that Isler and if you identify that there's missing documents , like say your deployment , your deployment record is not correct . And then we have to have a process in place to allow you to update that deployment data , update the exposure information data . Uh So a big , big heavy lift here to make sure we get access and then once they have access a process in place for correction of the records , next slide , please . Uh More , it just like I said , there's , there's a lot of Congressional and White House guidance and this is specific for the open burn pits uh going through from F Y 2010 all the way up to F Y 22 . We've had uh various laws directing us what to do with the burn pits . Uh One back in F Y 2010 , the prohibition on the disposal of covered waste . And if you wanna know what covered waste is , it's a term that we have in our policy document . It's hazardous waste , medical waste , tires , treated wood batteries , plastics , munitions , uh asbestos , you name it , those are considered covered waste . And there's a prohibition on burning covered waste in the burn pits unless you have uh authority to do so . And we'll talk more about authority to do so with the burn pits shortly here . Uh Then section uh F Y 2014 more clarification on , in fact , they just added more material to the definition of covered waste . And then we get into uh uh congressional concern , White House concern about when are you gonna phase out the use of burn pits ? And then um section uh F F Y 2022 . Section 3 16 , that was a big one . And that resulted in only the Secretary of Defense and no one else . He cannot delegate to anyone else . Only the Secretary of Defense can approve the use of a burn pit overseas and only the four star geographic combatant commander can submit a request for the secretary to review to allow them to use a burn pit . And trust me , they have to meet , they have to truly explain why a burn pit is needed and why other alternative disposal methods are not available . But again , it's that level of approval , four star submits and the five star if you will , the Secretary of Defense , he decides whether or not to authorize that uh use of that burn pit for up to 100 and 80 days . All right . As far as uh provisions for exposure monitoring health assessments and health records , uh there's a couple of N D A A s in there that basically say add additional information to these assessments that you perform on the troops I E the period . The annual periodic health assessment , add more questions for the troop to answer with regard to his or her . Exposure concerns . Same way with the pre and post deployment health assessments they're required for deployments . And we've had , we were directed and we have added additional questions regarding concerns about exposures , whether it's ambient air burn pits or other exposures . We asked the service member to check this box . Yes , note and other information that informs the medical encounter with the provider uh during the post deployment health assessments . So , uh again , good direction to do that . And we've , we've met those requirements and I talked about the 744 capabilities Assessment down at the bottom that goes from everything to assessing how you do , what we call tactics , techniques and procedures . I e how good are your preventive medicine units ? Teams , individuals at going into these locations , the aero locations , these contingency locations and sampling uh for occupational environmental health hazards and , and , and then advising the commanders on what to do . It gets down to that level of what we have to do as far as assessing how well our , our environmental assessment uh uh capabilities are next slide please . And these are for uh outreach and education . I can tell you , I personally will say I'm very uh I'm very pleased with the comprehensive Outreach and education . We and the VA have in place and put in place over the , over the last three or four years . Um It , we had N D A a direction to do so . That's fine . We , we needed to do that and means where we outreach and educate our service members and veterans , our respective dod and va websites . Uh We have a requirement on the dod side to physically mail a flyer to those service members who are eligible for the Burn Pit registry because of where they were deployed . And then we put uh information in what's called a leave and earning statement . We do that about three or four times a year . Put a , a quick blurb on there if you will . That says you may be eligible if so or go here to this website and check out to see if you are eligible . We use social media , we use newsletters . Uh Again , I think we have a very good program in place to provide outreach and education , not just on the burn pit registry but on exposures in general . Next slide , please . Uh This is uh just showing you um what I mentioned back . Uh As far as the , the Secretary of Defense , he put out a memo back in October . Uh further stating that only he is the the sole approval authority for any future use , use of open burn pits that was followed by the undersecretary of defense for acquisition and sustainment . Uh They owned a policy for burn pits that dod instruction 47 15.19 and additional guidance on the reduction of risk associated with exposures to burn pits . And if you are authorized to have a burn pit , here are the criteria you must meet in order to , to minimize and mitigate exposure . So these are two very important memos that came out last October further emphasizing the department's desire to reduce and or eliminate the use of burn pits via alternative technologies such as tactical incinerators or impro you know , improving uh the engineered burn , uh not burn pits , land fields , landfills , incinerators , other means other than uh open burn pits to , to dispose of the waste . Next slide , please . Ok . So that was a uh and uh guess Brian , how much time do I have on , on the clock for me ? Oh , I've got about eight minutes or eight minutes . So uh again , a quick summary of the burnt , the exposures of concern . Um not noting that these exposures of concerns are in the workplace , in the training environment and contingency locations and even at home . Um We know there's continued high troop and veterans concerns about these exposures and there always will be and uh continued high congressional and White House concerns about these exposures and therefore the requirements that they issue for us and the va to , to enact . So our focus is on the reduction in in elimination of exposures where possible . Uh If , if there are exposures and you can't eliminate , then mitigate what can you do at the workplace . What can you do at the deployment location to mitigate the exposures that you have identified and then monitoring um the individuals uh providing the and and creating a an exposure record . You'll see that with the individual longitudinal exposure record , uh providing the medical care if needed when needed uh health effects research . So taking all this information that we have provided to the epidemiologists and the health effects researchers identify our cohorts . So that we can better understand the potential outcomes , the potential health outcomes associated with a given exposure . And then therefore use that information to go back , as I said , eliminate , mitigate and have better care for the service members and veterans . And then of course , supporting the disability claims on the va side as well and we'll talk more about that later . All right . So , questions for the last five minutes . I'm , I'm in the chat room . I know I'll just pick up . Um , let's just go with um , uh Jessica Myers . Are you aware that there are many service members with service tickets into the burn pit registry ? Because deployment information is incorrect and cannot be corrected as well as not being able to add countries that were not reported in the registry . So I , I know we're updating the registry . Doctor Sheep helped me out here that we , there was additional um , countries that we were told to add to the list of eligible countries . And therefore , we've done that if , if a service member has deployed to one of those countries and they're trying to register . But if it's not showing up that the va can't see that they were deployed to those countries , then the VA works with those individuals to , to look for the supporting documentation that indeed says they were deployed to Syria deployed to Iraq and , and obviously allow them to be eligible for the burn pit registry . Uh So I'm gonna add another question here . Do the legal limitations on the use of burn pits extend to local national contract of waste management . Uh Right now , uh There's right now , host nations are the ones that are managing the burn pits where our service members are currently deployed and meeting those requirements . If , if it's a burn pit that they're using to manage our waste , meeting those , they have to meet those requirements as well in terms of 2000 m down range from wherever the bib wack sites are , the work sites are . Um And then a like quarterly air sampling of those burn pits uh for obvious reasons . So yes , they have to meet those requirements if they're operating a burn pit um in support of the US base , that's there . All right , let's , uh , let me go back up . All right . Do we have any comments about the recently released reports about air crew cancer incidence rates in relation to the occupational environmental exposures ? That was in section 2000 N D A 2001 section fif 7 50 . Uh I don't have any direct comments on that . I was not involved in that research . Um I don't know how there's a way I can get back with you . Uh Lieutenant Colonel Kane , uh If you wanna email me , I can follow up back with you on that question about uh the recent report on cancer within the air crews . Ok . Um Let me see , trying to find All right . Let's see . Not seeing too many more questions unless I'm miss missing those . Are there any more questions if there's some just , uh , blast them in there real quick ? Ok . And if we don't , if I don't catch you here , we can catch it in the open session at the end of the other three presentations . And I think , uh , there might be one more from , no , that's just a note from Jennifer about the presentation slides are available . Ok . So Brian , I think I've hit my 25 minute mark , probably right on . Correct . You are good , sir . It's uh 1 28 . So we've actually got two minutes . But , ok , it's uh I'm not uh I'm trying to dig through , see if there's any additional questions that I haven't addressed . Um See , let's see here . Uh Once in a while we will get a vet that had been on a special mission , not necessarily showing on their military orders . How do we proceed ? That's uh that's a good question because we'll have some special operators on the , on the socom side that where they are , where they were probably will never be declassified . So , uh Doctor Ching , if you can help me with that one in one minute , in terms of folks that their deployment location , information is classified , not available for the va how do they work with , let's say a special forces operator to verify deployment and then obviously make uh the eligibility for the burn pit registry , not trying to put you on the spot Eric , but that would be a va um , I think that would be a va process to verify Steve . Hi . Um , why don't we get through my brief section and , and I will circle back and , and answer the , I see at least three questions about the burn that , that , that I can comment on and I might hit on part of the answer but , but uh I can circle back to them kind of later if that's ok . Ok . All right . So I know I'm at the mark now . So it's good timing . Uh So Eric Doctor Ching , I will now uh pass it , pass the baton to you for your presentation on airborne hazards and the open burn Pit registry . And I look forward to more questions at the end of the session here today . Thank you very much . Yeah . Hi . Uh Good afternoon to everybody and just a coms check . Uh You , you can hear me , please . Um assume . Yes , I , I'll proceed . Ok , let's um go to the next slide . Yeah , I , I'm a doctor Eric Ching and um I work for the VA I'm a retired army , uh left um a the army at the O T S D in 2018 . I've been working at the VA pretty much since then . And one of the good parts of my job is that , that we are very much embedded with dod you know , I work with Steve Jones and others pretty much daily and , and certainly weekly . So let's go to the next slide and this is what I hope to cover today . Um , you know , first what , what is the registry ? It seems like a simple question , but it , it can be kind of complex and then I'll briefly talk about all the different exposure registries that we have in the , in the va uh , in , in our office , health outcomes , the military exposure or , or our home . Um Then I'll get into the , you know , kind of the nuts and bolts of , of this lecture . And that's , that's a burn pit registry . And there was a recent report , uh put out in October of 22 from National Academies is really going to change the direction of how the , the , the burn pit registry will , will , will be run and , and definitely spend some time on that . And finally , I wanna talk about a new program uh called Vet Home and I got one slide on that . So next slide , please . So what is the registry ? Um If , if , if you ask people is , it's one of those things , you'll get 56 different answers . Um You , you , you know , from people . Uh um but what , what it is is it's a system of records that , that you collect and maintain AAA database , uh which be allowed for , you know , additional review and usages . And there , there , there's two broad categories . There's disease based . So , a cancer registry is a disease based registry , but all the ones we have are based on an exposure and , and the airborne hazard and burn pit is a particular matter and , and , and , um , you know , you know , from burn pits , diesel fuel and all the other things that are kind of produced in a combat zone , you know , especially in Southeast Asia . Next slide , please . Ok . Um , Exposure registries , um they have strengths and weaknesses and , and on the good side is it's a uh list of it can be a list of all the people and this will be a strength of the future re registry that we hope to include everybody who , who is eligible but versus those who , who um you , you know , join the registry or , or can join the registry because because as outlined in the questions , there's definitely issues with , with , with getting in there . And um I guess another big weakness with the current registry is relied on self reporting information . So you're asking people about events that happened 10 2030 years ago and they just don't really remember or what they do remember . May , may , may have been changed . So there's a lot of um kind of bias , you know , we , we recall bias with , with , with the uh registry and the current um con configuration . So , next slide please . And these are all the um registries that , that are the exposure registries uh , in , in , in the VA and , um , you know , you know , the burn pit , well , the Asian orange is , is the largest but they've been around , you know , much longer and about three quarter of a million . Um , you , you know , Vietnam Air veterans have joined and , um , then , then we have the Gulf War registry too , which , which is very similar to the burn registry also . So , so I , I'll , I'll show you a slide of that that goes over the similarities between the two . And then we have others that are based on um fairly specific exposures . We have a radiation registry , but that was for people who were , um we're working in nuclear programs . Uh you know , you know , a actually we , we have P O W s in Nagasaki and Hiroshima in that area and then they're , they're eligible for those dry too . So that's a , a fairly , um you know , narrow scope of , of who can join . And then we have uh specific exposures , toxic embedded fragments . People have um embedded metal from shotgun blast , uh I E Ds and , and that , that couldn't be safely removed . And then D D U um essentially a screening if , if you were um more likely not to have received um brief in D U munitions uh from a friendly fire or , or , or your vehicle being you , you know , you know , hit and , and there's some similarities between these , that they were all um chartered by by a congressional law . Uh , so congressionally mandated and they all have a , um , a free medical exam which is voluntary . You , you , you have to ask to , to receive that . And the big difference with the burn pit is , um , for all the others you start with the exam or the test , uh for , for the , uh , everyone has a burn pit . You can go online and , and , and do the online questionnaire and then you can possibly get the exam later if you , if you want to get the um exam . And one thing um that , that , that's out there that I got to join the registry because it's tied to the claims process and , and that's definitely not true that they're , they're totally independent of each other . Uh being the registry can help your claim . Y y you know , the documentation produced but , but it's certainly , um you know , not , not , not required . So , next slide , please . Ok . Um Eligibility is based on location . So , um you know , essentially a Southeast Asia and the uh bodies of water around South Southeast Asia . And then , um there's Djibouti which had a , you know , very big , um you know , you know , burn pit and , and then um a Afghanistan of , of course , um you know , that , that , that was part of the initial law . It , it was really focused on burn pits in Afghanistan and Iraq . But , but uh we , we expanded it and , and recently we added Uzbekistan Syria and Egypt . And that raises the question . Um , you know , not , not a day goes by , um , where someone would like to join the registry . I , I was in Vietnam and , and we burned trash . Um , you know , and you , I should join this registry and um , this will go back to the purpose where we're really looking at this to be surveillance . You know , you know , it's not a place just to document your exposures , but it is to get a group of people to do surveillance . So , um you don't wanna say that , that you didn't , you weren't around burning trash , you know , you know , from Kosovo or , or , or even a A RT C , you know , you can be a con and , and , and you , you're working with Bernie trash too . You just can't join the registry but , but it also doesn't mean you don't have health problems too . And , you know , that's how you talk to your health care provider about . So , next slide , please . Ok . Um You know , you know , the two parts and roughly uh the , the , the , the first is the online , um you know , questionnaire where , where you , you go in , um you have to register and that's where a lot of the um questions I I saw were focused on issues and problems , get , getting into the registry to begin with . Uh Once you do that , um you know , once you get registered , you get your deployments down , there's a series of questions about 100 and 40 . But in , in , in reality , um , it's about 100 and 60 because some of them have sort of a follow on to , to , to the main questions too and , and , um , it is rather time consuming , you know , initially we said , you know , 40 minutes to , to , to start . But we , we kind of change that but most people take an hour and 20 and if you have many , many deployments , you , you can take , you know , up to three hours and that , that , that's , um , you know , I talk , talk about the redesign . That's definitely a weakness of the current one . Um Once you finish the , um , online exam , then then you're eligible for a free in person exam um at the VA for um , National Guard Reserve and , and uh veterans , um , a active duty . We , we , we can't , the VA can't see them . So , so , so we kind of rely on it on an M T F . Um , you , you know , you know , for , for that part and um doctor will , will talk about the exam , um , you know , you know , kind of in detail , uh next and what that uh consists of . So , next slide , please . Ok . Uh How , how do you start ? Well , uh you , you , you found this on the web is , it's located off , um , you know , the VA website , you can Google everyone has it and burn pit registries and you can pretty easily get to this , what we call the home page . And if you click get started it , it'll take you to the , um , login , uh , place and I wanna try to answer one question here . Um , if , if a better wants to know our , our search wants to know if they signed up or not because , um , we , we , we did , um , had , had a group to do , do some , um , you know , sensing session , focus sessions with , with , with veterans and some people just don't remember it . It's not a really memorable part of their life that they did it maybe four or five years ago . But you can log in and download your , um , your , your questionnaire if , if , if you're in it . So , so that's the answer to one question , you know , you know , veterans finding out if they were in the register or not , you can go in and check and see . Yeah , I'm , I'm , I'm in or , or , or , or , or I'm not . Uh but any event , um this , this is the home page , you know , click , get started and it takes you to the , um , you know , to the next steps , next slide , please . Ok . Um Kind of walking through the steps there , there needs to be a um or there is a secure login um measure for , for dod . Um That , that's mostly DS login on the va side . We , we've have migrated and add it , add it as a log in site . Such as my healthy vet and , um , others . Um , you , you know , if you're , if you have that card enable that , that , that'll work to , to log in . But , but many veterans have to get a password with , without AC C or a PV card . Um , the next step , once you're in , you have to sign a consent form and some people choose not to do that . Uh , uh , they say no and , um , you can go back later , you know , if you , if you do want to proceed . But um , and , and that's sort of another rule about the registry . Um Very few things are dead ends . Um Except for a few , you know , always come back and um if you change your mind and , and proceed with it , um ideally your um deployments link up with data provided from D M DC . You know , there , there's an automatic feed and , and if you link uh with , with the D M DC database , you're , you're um deployments are there . However , um as , as point out one of the questions , some of them are just not , right . Um You know , you know that the they , they're um you know , for a variety of reasons . Um You , you know , a lot , a lot of the deployment sections are based on ID card swipes when , when we do air travel and if your car to get wiped that day , it'll look like you stayed at the place you , you , you started at um , but , um , but , but there is a way to correct that , correct that record , you know , you know , with , within it . Um , I guess unfortunately not everyone , um , gets this automated step that's about a third , do , do not . And this tends to be in , um , pre 9 11 . So the Desert Shield , Desert Strong group , uh special forces because their information tends to be classified . You can't migrate over . And , um , those and this is definitely fact service members , those who redeployed in the last 90 days , there's kind of a lag time between the data getting mature uh from , from the services , the DMV C to , you know , to the D A . So , so , so we , we , we , we have a challenge with , with , with that group there . Um However , we do have a process to place that there's a , there's a team um about about four or five people that , that most of the time spending do what we call manual re reviews . Um They'll , they'll um once you request that manual review , they'll , they'll go to I , that , that that's the first place to check . And then they , they have some other databases too , um that , that they can check if doesn't have any information . And then kind of the , the thing that last resort is , can you send us your deployment orders or , or um or your , your D D 2 14 , you know , your veterans . So some other official document about your , um deployments and the , the group um managing this is that everyone has a center of excellence in East Orange , New , New Jersey . And they're kind of the research hub for um the , the this topic too . So , so it really made sense for them to own the data that , that , that , that , that , that comes with it too . So , and then they , they've developed a um probably not as robust with the pack act with , with , with young people joining , but , but , um , when we were 60,000 , it , it was , it was a pretty good team that , that , that got through these manual reviews , um , you know , fairly quickly , next slide , please . Ok . Um , just sort of the , um , the data and , and , and the um , in , in the registry and , and then just try to kind of walks you through , um , you know , you know , what , what , what kind of happens . So , so , so the first thing is , um , you signed a consent and we've had 22,000 people who did not and , and they can come back and do it again later if , if , if they'd like to , um , the next step is what we call eligible . You , you're in the registry but you haven't , um , finished your questionnaire . And , um , this data is as of , of one January this year , uh , we had to get the slides in fairly early , you know , you know , for this presentation . Um , but , um , we , we've actually grown by 30,000 , um , you know , you know , this quarter , um , and , and , and actually two more days left in March . So it'll be a little bit bigger . But any event , um , the , the 1 73 is people who started but did not finish , um , variety of reasons . It's too long . They , they , they don't , you know , don't , don't like it or , or , or , or they're frustrated with , with the , um , kind of the speed of loading and lots of other reasons too . Uh , you know , they just want to sign up and , and they didn't really want to answer all these questions to begin with . Um , so they , they are in the registry too but , but what we really follow is the participants , um , th those are people who , um , got in , finished the questionnaire and , um , finished . So , so , so , so , so that , that we , we kind of look at them as the ones being done and that , that's where we're at 3 , 380,000 , you know , you know , you know , we're at right now . Um , so that brings us back to the non and you people can , and , and try to join if , if , um , they've deployed or maybe not even deployed . They , they , they think they can join , um , you know , they get in with their DS log in but , but unfortunately , you know , the way the rules are , we , we , we have to put them in a non eligible . Um , you , you know , category . So , next slide , please . Ok . Um And , and the system is a bit dynamic . Um um Everybody in the service right now is either active duty guard or reserve and they someday will be um a veteran that they'll either be separated or retired . So it , it um reconfigures uh um the , the , the uh separation information um gets transferred , you , you know , you know , through , through D M DC to , to the registry again . So , so we , we know um when , when people do leave the service , um small number of unknowns and then , then unfortunately , um nine or nine or five people who joined the registry have , have , have passed away and this is um kind of all cause mortality . So , so it includes um suicides M B A S A A and , and other traumatic events , you know , you know , some combat um injuries too in , in that group . But , but of course , it includes um medical causes um cancers and , and , and other reasons which , which is really why the registry is there to , to try to get a handle on the these exposures and , and , and medical , you know , diseases next slide , please . Ok . Um just numbers of a year and , and when it first started in 2014 , you know , you have , you know , fairly small and , and it certainly has grown . Um , every year I , I started in 2018 and um 21 22 were big years . Relative to the others , you know , we we we we doubled uh relative to 26 7000 , but we're on track right now to get 100 and 20,000 , you know , 30,000 in one quarter . So , so 2 , 2023 will , will , will be a very big year for people joining . Um probably big , biggest reason for that is , is , is the emphasis on that the Pack Act and the VA is actively screening people who come in for appointments for , for exposures . So , so they're getting redirected to join the registry too . So , so , so it's probably a combination of all those factors next slide , please . Ok . Uh Just some uh high level events , you know , you know , big reports on on on the burn pit registry and in 2011 , Institute of Medicine now , now the National Academy of Science and Medicine , um they , they did a , a comprehensive study on , on burn pits uh really focusing on but , but other places too and , and probably the biggest thing they said is um you , you may not just want to focus on the burn pits , you know , there's lots of other respiratory issues , you know , particularly matters from the dust of , of , of the desert and um and , and , and , and other things , you know , and other things from deployment too . So you got to kind of expand your your aperture . So , so that's , that's where the airborne hazard part came in conjunction with , with the burn pits , um , congressionally mandated in 2013 . Um , it , it was launched in June , June . June 2014 may , may seem like a long time . Um , 88 , 18 months . But , um , I have to say with I T systems and getting the right questions and setting things up , they , they , they moved pretty quickly . Um , you , you , you know , under what they , what , what they needed to do and , um , you know , you know , we're approaching the 10 years now , um , you know , next year in 24 but in , in February , um , you know , 17 , um , Nason did another review , uh , required by the original law and they had nine recommendations to improve the registry . Um , and , and , um , you know , by and large , those are all , you know , follow through on , in fact , in fact , they're all followed through on , it , took , took a while for a few of them . And then , um , in 22 the O I G , um , did a report , um , kind of pointing out that , that , uh , many of the people who requested exams did not receive that , that exam which , um , was largely due to COVID and , and , uh , resources being diverted for , for COVID response . Um , but , but , but we , we've , um , you know , kind of recovered and , and , and have a very concerted effort to , to make sure all , all the veterans have been offered that that exam and then , um , kind of finally the Nason report in 2022 at this point , I want to transition to that and I've been hinting about big , big changes to , to the registry and that'll , I'll , I'll show you that on the next slide , the next one , please , right ? Um , ok . Um sort of the bottom line is , um , you know , you , you've been at this for a while and it's just not really doing what you think it should have done . You've collected some really good data and , and um and , and I mentioned the center of excellence and , and they , they have that and they're actively working with the data they have . But um you know , you know , you know , this is a fairly high price . I i it , it takes people a lot of time , you know , there's a lot of high uh frustration , you know , you know , getting in and you , you just , it's just not where you want it to be . So , so you should think about doing it again and , and , and that's what we're gonna do , you know , next slide , please . And I wanna say almost all these things are not right now , but , but this , this is how we , we see that the new registry is gonna be , you know , you know , the design , um you know , there's some , some approvals and other things that need to happen . But um you know , I talked about the phone book uh of , of uh having the whole roster . And that is our plan is , is to take everybody that we can find that deployed to the theater eligible , you know , you know , population and , and put them in the registry . We want to cross reference with the uh prior registry to make sure all , all , all in two were in one , you know , 11 and two should equal each other . And then looking at other um kind of databases that there's a registry on , on um Desert , desert , Desert Storm Cross resume of that . So , so we really want to make an effort to include everybody . And part of that is , you know , as much as we try to get everyone . I'm , I'm sure we'll miss people too . So a way to check and , and , and I is kind of the plan to , to , to um , so , so when , when they have access to the is to go and say yes , yes , I'm in registry two and , and one for that matter . Uh um and , and um you know , that , that , that way they know they're , they're in the registry but , but this will um be no effort on the veteran at all that , that they won't be asking any questions that there won't be any DS log in . So it'll be much less , you know , burden you , you know , you know , to all . Um And , and this is a good time to talk about the purpose of the , of , of the registry . The purpose of the redesign is , is to really do surveillance uh of the , the , the entire cohort . Um not , not just the people who could get in or , or , or self motivated to get in but , but , but the whole group and , and to communicate what we find , you , you know , you know , with , with newsletters and articles and that was really the purpose of the um registry to begin with even though , um , you , you know , you know , at times maybe we vacillated , um , you , you know , what , what , what , what , what it was for . Um , now , now , maybe , maybe a good time to talk about the exam and , and , and the um exam is a , um , kind of a whole different um thing that then , then the registry itself , you know , right now it's , it's , it's uh configured with , with , with the registry , you know , you do want to too , but , but post , um , but post , you know , when we're in this new system too , we're not gonna have a dedicated exam with , with the registry , but uh , uh will be eligible for , um , getting uh , essentially uh uh an exposure assessment to talk about their deployments and , and , and exposures and , and document it . That , that , that , that's where most people really want to do . They , they want to document . So , so there's a record of it or , or , or , or talk about their health condition , you know , you know , they're concerned that , that I'm going to get sick or I'm sick right now too . So , so , so there's a lot of value added , I think to the exam , you know , you know , what , whether it's embedded with the registry or not . But in any event , um , 11 thing we're planning to do and , and , and , and , uh , Steve Jones , you know , mentioned about the phase out of , of , of burn pits . And once we're at number two , if , if you deployed to the theater after September 21 . So if you're deployed right now , um , that , that , that , that , that group will not be migrated into , um , into the bur pit registry . So , so it , it , it kind of closes for , for , for enrollment bar bar and the people we miss . Um , so let's go to the next slide , please . Ok . Um I , I mentioned , you know , eliminating the questionnaire , uh , um , and , and , um , you , you know , talked about the , the , the , um , exam but , you know , we got a lot of good data from that . So , so , so people wondering , hey , you know , did I , was that not a good use of my time ? Was it , was it bad ? I joined ? No , you know , definitely not . Uh , um , you know , we , we , we thank everyone who's joined , you know , you know , for doing it , taking the time and , and , and the center of excellence is putting your information to work to , to , to help , you know , help veterans down the road . Um , Now , now , as far as the exam goes , um we , we are , um , you know , you know , training primary care and , and , and if you're um primary care provider and your patient , um you know , veteran has concerns about uh their exposures , they , they should go talk to their doctor about it . And that's kind of where um doctor Mansi is going to be focusing too . Is , is your , your , your , your patient has exposure concerns . You know , what , what , what do you do ? Um Not , not every veteran rolls via health care and , and um we , we have a program coming up called Be Home that that'll be available for , for that group for , for a um in , in person assessment . Um a , a actually virtual assessment for vet home . But , but I'll talk about that on , on that slide , next slide , please . Ok . Uh And be home as , as as promised . Um Right , right now , um if , if , if you want to get a registry exam , you're in the reserves . Um We , we used to say , um contact your local E H clinician or coordinator . Uh And then there , there's a website that , that , that you can find that . Well , we , we shifted with the I G report that we're reaching out to people who , who checked that . There's a question in the registry . Do you want the exam ? So , so we shifted a bit , but that all said we , we've had um issues with , with resourcing where where , um , the , the , these e clinicians and coordinators aren't dedicated positions , uh , they wouldn't get filled . So there would be gaps in , in providing that , you know , you know , the coverage too . So to kind of get around that , we're , we're building a team of , uh , 40 providers . So , so it's like an E A clinic , um , on steroids , um , you know , 40 providers with 30 support staff that , that we're calling a call center . So , so , so , um , uh veterans and service to when , when there's up and running can call , you know , we , we can't necessarily see you but , but we can try to get you to the right place to answer your questions . Um But , but they're there to take calls and to do outreach to , to , to target people , you know , you know , for their exams . Um We hope to be in um I O C this , this uh summer . Um And , and all the , all the visits will be done virtually , uh either by video connect or telephonic too . So , so all these providers will be working um working from home on this project . So , ok , next slide , please . And I think this is it for me . Yep , this is it . Uh , do we have any um time for questions ? Um Let , let's see . Um something about um Korea . Um Yeah , that , that , that's not part of everyone has their burn Pit registry . Um And , and , um , you , you know , once again that that , um , air , air air quality is , is a , um , issue in , in the world . Uh , um , and , and , and certainly where , where our , our soldiers go , uh , soldiers , airmen , marines go , um , you know , deployment that there's poor air air quality . So , so that's AAA large concern . But , but the , uh , everyone has a burn pit registry is not focusing in on , on Korea if I can remember the , um , yeah , let's see , 98 Bosnian on the registry . Um Yeah , it , it , it kind of the three big criteria were , were the desert um combat operations . Um You know , you know , not all the countries had combat operations but you , you know , you know , they're pretty close to it . So , so once again , the , the , the registry is not for everyone . Um and , and , and for the reasons I , I I explained is , is , you know , we really want to be a surveillance and , and if you put , put everyone , you , you're , you're kind of watching everyone . Uh um You , you know , it , it gets unmanageable too and , and that doesn't mean people who went to Bosnia may not have health issues from their um exposures . Um But , and , and that , that , that's something you talk to your um you know , provider about . Um Yeah , yeah , Major Jensen . Um um you should talk to your um provider about your um um well , uh and , and unlikely to be a burn pit exposure . Um You know , Steve Jones mentioned um , they , they , they , they weren't everywhere but , but once again , you , you know , this is the um industrial level trash removal but , you know , you know , burning trash is still kind of a common practice . Um And , and you should see your provider about that . I , I , I can't , um I can't speak about um if , if they have 100 10 va disability and , and how this translates to reserve services . Um I don't know about that . I , I , I would think that they would probably need to go to uh M E B like , like , like say , you have 100% for asthma which would be pretty severe asthma and , and , and they probably need to go to an M E B but , but um you know , there , there , there's probably ways they could be 100% and still serve . Um But , but that , that's sort of out of scope for from my knowledge base . All right , sir . Well , I think time is up for questions and we're gonna move on to uh Doctor Mansky . Ok . All right . Uh And you're able to hear and see me . So let's get started . I have some preliminary remarks before getting to my slides . Uh First off , uh Greetings to O D N VA health care colleagues . Thank you for participating today . Our brief time together 20 to 25 minutes is intended to fill in some of your possible knowledge gaps and provide a stimulus for self study . I'd like to say upfront that it has been a distinct privilege to have worked with Mr Jones , Doctor Ching and Mr Van Grift in putting together today's webinar . I also wanna thank the professionals behind the scenes who assisted us . Thank you . All . My portion is targeted at primary care providers who will be performing airborne hazards and open burn pit , environmental exposure exams . But it should also be of wider interest . I recognize that some in the audience are highly experienced with such exams . However , my working premise is that for a good number of medical personnel , this is a rather new undertaking for those new to this work rather than trying to get these exams done in your usual 15 to 20 minute primary care time slots . I suggest asking for longer scheduled times . I have four objectives for our session . One equip you with how to deal with service members who come to you with concerns over the military environmental exposures that occurred on deployment two , an approach to the focused airborne hazards and open burn pit registry , medical exam three , where to find resources to expand your knowledge base and four , how to communicate what you find in Isler with your patients before I get to the slides to help what I have , what I have to help . Put what I say I have to say in context , I post four rhetorical questions with answers . Uh First , what are open burn pits , you know , it may not be obvious . Uh Answer burn pit is a variably sized area devoted to the outside open air burning of trash . It was used to get rid of collected solid waste and was a common waste disposal practice in overseas military deployed settings . There may have been more than 250 burn pits in multiple combat theaters , largely in Iraq and Afghanistan , but also in many other countries , they varied in size from relatively small to massive that covered many acres up to 20 acres in Bala . For instance , it's hard to envision but an estimated four million veterans who were deployed in the West , 30 years were exposed to burn pits and can file va claims . Second , what was burned in open burn pits ? Answer the intent was to dispose of solid waste or garbage by burning other waste management options of landfill recycling . Our use of incinerators were often not feasible . Necessitating open burning , a variety of hazardous waste , medical waste and human waste were also burned and these open air burn pits . The VA provides an exhaustive listing of what was burned on the airborne hazards and open burn pit registry website . Third , what was the composition of the smoke that arose from open burn ? Pitt's answer . The composition of the smoke . E one has a complex chemistry known as PSIS chemistry . The chemicals formed from burning varied from burn pit site to burn pit site and in the same burn pits site over time , the resulting thermal decomposition products were dependent on what was burned , how hot the fire got and how long it burned , but generally found were variable amounts of particulate matter , volatile organic compounds . Polycyclic poly aromatics , dioxin sulfur dioxide , nitrogen oxides , et cetera . Fourth , why does exposure to burnt pit smoke ? Medically matter answer , exposure to toxic smoke may have acute effects such as eye nose , throat , lung irritation and cough . But more importantly , it may lead to long-term health consequences such as chronic respiratory conditions and cancers . Those potentially exposed to not only personnel working in the pits but also many others with variable distances from the pits , with exposures depending on the size of the pit distance from the pit smoke plume characteristics and local meteorological conditions . In fact , little surprise , the smoke may have traveled not only across the camps but beyond outside the perimeter . Uh Please now fasten your seatbelts as we quickly move through the slides . Well , I have uh 27 slides that will be highlighted not read . They are meant to be used for your later reference . This is where I tell you what you need to do and how to do it . Plus some background information . Please note that 10 of the slides have duplicate titles that are just continuation slides . Please also note that the slides will be made available for download . There will be some repetition with what Mr Jones and Doctor Ching presented but repeating some important points is a good thing . All right , let's jump in and begin my slides . Uh slide . We're now on slide 36 . What I provided is my recommended approach to the military environmental exam exposure exam with the suggested H and P format diagnosed the codes and went to do a specialist handoff and which specialist to use the content of today's presentation is largely that of the airborne hazards and open burn pit registry exam . There are other exposure based registries of which to be mindful , but they are not pertinent to today's talk . Uh For instance , the VA as Eric mentioned , Western runs the Vietnam , Agent Orange and Persian Gulf War registries . Uh two lesser known registries perhaps um are those run by dod , for instance , operation Tomasi in Japan uh and K two uh in Uzbekistan . In short , both the O D and the VA maintained uh registries deployed personnel were exposed to smoke not only from burn pits but also from burn barrels where they burned poop . Uh incinerators operated near our bases , wildfires , burning of trash by the local population outside the bases and the ever present air pollution in some places beyond the legislation . Little surprise that burn pits have been in the news . For instance , one article with a particularly obnoxious title was they proudly served their country but were breathing toxic air that could kill them . Thousands of dead or dying . Us veterans were sickened by war zone burn pits but the va does nothing to help them claim families . If you can imagine this was in the daily mail from the UK date of 21 . February 2021 . And that it is a given that plaintiff attorneys have joined the fray all this to say and I emphasize this should work in this domain matters a great deal . Please consider it to be important work despite being one more addition to your already over full plate . Next slide , please slide 37 . Today's presentation represents VA and D A dod cooperation at its best . This is a joint webinar between our two agencies . Behind the scenes . We do a lot of other collaborative work with work groups , development of clinical practice guidelines , training , et cetera . The notion is that by working together , we could deliver a seamless continuum of care for service members who ultimately transition to becoming veterans who try to be in sync to the greatest extent possible . Next slide please . I have two slides for this topic . There are two parts to the uh H O B pr medical exam . First , the web-based self assessment questionnaire completed by the patient . Second is your medical evaluation . And um as has been said before , this is separate from the mandatory dod separation , retirement exam and the optional va compensation and pension disability exam . There is great value in it targeted burn pit registry , primary care encounter service members are able to get their burn pit exposures addressed by the military health care system and are able to get this documented into the service , medical records . Your documentation helps with their disability claims process . When the va disability examiners review their military health records . Next slide please , by having knowledge of A H O B P tools and information , you are empowered to direct service members to highly to high quality educational and informational resources . You're also in a position to listen to and understand your military environmental exposure concerns and then to medically evaluate them to make appropriate referrals . When indicated . This is also a time to explore their perceptions of possible harm and misinformation . Admittedly , there can be uncertainty around the extent of their exposures and even if they were exposed the most helpful tools , the individual longitude exposure record to be discussed at it to be discussed at length by Mr Van Der Griff . Next slide please . Mr Jones covered congressional executive and dod requirements to form the legal basis of our obligations to service members and veterans regarding the military environmental exposures . Doctor Shin provided a background to registries , discussed the A exposure registries and the A H O B pr . In some detail , this slide provides some additional granularity on public law . 1 12 , 2 60 of June 2013 that established the A H O B PR and also the Pack Act of August 2022 that provides health benefits for a number of military environmental exposures , not just burn pits . Next side , please . I have two slides for this topic . Our assumption for having a medical exam is one component of today's webinar discussion is recognizing that environmental medicine , environmental exposure and registry type medical exams may be unfamiliar to . Many of you may have already found that many service members have military exposure , health concerns . They expect that you can meet their needs by being able to have a meaningful dialogue , be empathic and that you are well equipped to provide a meaningful medical evaluation . Moreover , they can or will soon be able to access the perf personal information in and expect that you can help them interpret what they are saying to remedy this knowledge gap . We have provided you with some tools today . Next slide please in your medical encounter document your patient's exposure concerns and your medical findings . Consider us other risk factors and other exposure categories that may contribute to the totality of what your patient is experiencing . For instance , occupational exposure , cigarette smoking and vaping decide whether their symptoms are active or inactive , acute or chronic and what you feel comfortable working up or what needs to be referred to specialist . Next , so I please , this is my uh bluff slide . The next four slides are on toxicology fundamentals emphasizing terminology . I recommend that you become familiar with these terms as they will help frame your conversations with your patients , words and perceptions matter . On this slide . It takeaways that exposure doesn't necessarily equate to dose or harm or development of disease . Next slide , please mention is made of the concept of a completed exposure pathway , which is important to appreciate a harmful biological effect can only occur if there is both exposure to a contact with a toxicant and entry of a toxic into the body by , by whatever route of absorption or ul ingestion or transdermal moreover exposures may be acute chronic and to a single agent or chemical mixtures . Many factors are replaced to whether toxic effects will result in disease , including the specific chemicals involved doses , genetics , age underlying chronic diseases , immune status , et cetera . Next slide please . On this slide , I've provided the distinction between hazard potential to cause harm and risk , a probability of harm taking place factors that can affect exposure and toxicity . The variable composition of smoke that may result depending on the materials burned . For instance , burning of plastics results in some really bad stuff being generated like dioxins , fins , P CBS , et cetera . I've also listed the important industrial hygiene hierarchy of controls . Some number of your patients may have worked the burn pits actually using appropriate respiratory iron , skin protection . At least some if not all of the time . The ultimate way to stop burn pit exposure is to is to prohibit their use . That is elimination which the sect F has now done . Next slide please . This is the last of the toxicology slides on this slide . I provide a terminology . I provide terminology used in the Pack Act and definitions for toxic substances and toxicity . Next slide , this slide provides further detail on the A H O B PR questionnaire and where the service members and veterans can obtain solid information online . Ideally , your patients bring your completed printed out questionnaires with them if they don't complete their questionnaire or don't bring the questionnaire with them . It is not a showstopper for the for the provider . Next slide on this slide , you will see where the provider can access the questionnaire if the service member is completed but not printed it . The solution is on the website . Next slide . This is the first of two slides and presumptive presumptive conditions to date . There are 23 presumptive conditions that you will find listed . I also have some have here some key points in what presumptive conditions mean knowledge of these conditions will help focus your H and P help you with some of the ancillary tests to order and some of the referrals to consider making what is unique about presumptive conditions is that the service member or veteran doesn't have to prove an exposure cause their condition . But rather it is given , it is a given that their deployment caused their condition . These presumptive conditions are established by law or regulation as under the pack Act . As an aside , most of the illnesses on the burn . Pitt's presumptive list . A va disability compensation ratings between 10 to 100% depending on severity . Neo on this slide , important to point out is that deployment is a proxy for exposure and unfortunately , as it makes our lives easier . D A DH A providers don't decide , I'm sorry , V H A providers don't decide burnt pit eligibility , inquisition . The va determines eligibility based on places , operations and campaigns and time frames . The important two step process that you see on the slide is if you were there , you were exposed and if you were exposed and develop one of these 23 conditions , it is related to the exposure . Next slide , please . Slide 51 starts the real meat and potatoes of my talk . How to most easily do your A H O B pr medical exam . There are two history slides . This first slide points out the need to carefully review the long A H O B pr questionnaire and also what should be included in your review of systems . Next slide please . The second history slide addresses deployment , history and exposure questions to ask the patient may or may not know the answers , especially if they had multiple deployments that are all blend together for them . We're on slide 53 . Now , um here I have provided the important physical elements of your focus station P as well as an tests that might be appropriate to order certain things should be consistently included while other elements are optional to notice that there are presently no biomarkers or , or markers of exposure So please , these are the I CD 10 codes to use for your medical encounter . The most appropriate will likely be those four that I've underlined . Other diagnostic codes may also be used depending upon what is disclosed by the patient during the encounter and what you find . Please be sure this is really important . Please be sure to add these diagnoses to their master problem list . Next slide please . In NHS Genesis , you may find these two snowed tax C T codes per an A H O B pr memo signed by DH A director dated one July 2020 . However , if these type codes are unfamiliar to you , no worries , you can still use the I CD 10 codes provided in the previous slide . Next slide please . On this slide , I provided the range of specialty referrals that might be considered triggers for specialty involvement to some of the additional tests . Specialist might order next slide . The next three slides discussed , the changes that are likely coming on this slide . On slide 57 the important points are to continue to do the A H O B P registry exams is currently instructed until directed to do otherwise to notice that the va will soon be pulling down its current burn pit registry and then sometime soon standing up a newer better burn pit registry . This is being done based in response to reviews by NASIM which is the National Academies of Science Engineering and Medicine . Published 14 October 2023 the 21 July 2022 VA O I G report . I've provided the links for both in case you're interested . Next slide , please . As part of the mandated registry overhaul by the VA the 144 question questionnaire will be removed and not replaced . Boss of the VA will no longer provide a specific A H O B pr exam as Eric mentioned , but instead will have it roll into general primary care encounters the veteran , however , can still request an exposure assessment from the primary care provider . The dod may eventually follow suit but that is to be determined . Next slide please . We're in slide 59 . Now on this slide , you will find written that the dot plans to strengthen the annual periodic health assessment post deployment , health reassessment and health assessment and separation history and physical exam by adding additional screening questions that relate to military environment exposures as Steve has mentioned . All right side 60 please . This slide starts the start of the second portion of my presentation out of available training and resources . This last part is a rapid fire brief discussion . Next slide please . I have two resource slides . The first one is for dod resource and the second is for va resources on this slide and slide 61 you will find multiple hyperlinks to dod resource and training among the best is the mandatory but well done J K O burn training . Uh which is number DH A tech US 035 . That is one hour of on demand training , broken into four modules . Some of the other recommended G gangster to be found on the health dot mill site and include the H C P clinical toolbox , the H C P guide a fact sheet and frequently ask questions next slide please . Uh This slide provides multiple hyperlinks to resources from the va there are lots of excellent resources listed . I urge you to explore and become familiar with the content of at least a few of them . I strongly recommend that you register for and participate in va risk training . That's war related illness and injury training with their periodic life seminars in the exceptionally well done VA wrist and AC PM . American College of Preventive Medicine Partnership training , which is free that leads to a level one military environmental exposure certification upon completion of five training courses and the successful completion of an easy 25 question , comprehensive final exam for this . You get both a certificate of completion and 5.75 C M E . Uh Stay tuned to level two set of courses pending . I might add , this is among the best training I've ever done online virtual training . It's excellent . I urge you to do it . Uh Slide 63 is a title slide uh for questions , how much time do I have left Brian ? Oh , you got about a minute , sir . Wow . All right . So this is my last slide . It affords me the opportunity to thank you for taking the time out of your busy lives to allow me to share some information with you . Uh I'd also like to put in some plugs for industrial hygiene and occupational medicine . If you have difficulty in interpreting environmental monitoring and site assessment data content in the Isler , use your industrial hygiene colleagues . If you need assistance with interpretation of medically related isla data as found in the poem , seek out O E M colleagues first try getting assistance from your local resources . But if you get stuck , please do not be frustrated . Instead reach out to defense centers for public health , Aberdeen , Portsmouth or Dayton to get I H O E M or toxicology assistance and causing I provided a whole lot of information , some of which may be new for you . Now is your opportunity to ask questions that I may or may not be able to answer . Please fire away . And finally , thank you for all that you do every single day . I I let's see , I can't see it . Uh was the presumptive condition list derived from S M epidemiology records ? Uh Eric would be in a better position how uh the va came up with the 23 presumptive conditions . All right . The last uh topic that we're going to cover today is the individual longitudinal exposure record . I don't know how much you've heard of this or even used it . Hopefully you have both . Uh So we'll , I'll do a , a review of a few slides that sets the stage for the most important part of this particular section of the seminar . Today is the uh de live demo of the exposure , the actual Isler itself by Mr Larry Vandergriff . And I'll tell you straight up , uh Mr Vandergriff , the project manager for the Isler over the last four or five years has done exceptional work working with uh the I T teams , the data teams va you name it . He's done exceptional work to lead the development of the Isler and to get us to where we are today . Uh This has White house visibility . In fact , we uh promised the what's called the executive office of the President , the Special Assistant for toxic exposures . We promised her that we would have a full deployment cap , full deployment uh capability by 30 June 2023 . This June . Now , what that means is that for all the functionality that we have previously received and been funded for , we will complete that just like any system that's new , just like MS Genesis or MH S Genesis . For instance , you're always looking to improve , to add additional functionality . For instance , the integration of the island with the electronic health record is an additional functionality that we will continue to build beyond 30 June of this year . And I'm sure as more people use the Isler particularly uh with the application to this uh the Pack Act that additional functionality request will be uh presented to us and we'll proceed on from there . Next slide , please . Uh Just like I , I'm not hung up on laws but we , I do get a uh I do respond to many , many congressional requirements and there's no shortage of those with respect to the is which is a good thing for us . It's this , it has the visibility up in the , up on the hill if you will the visibility within the White House and that's , that's , that's good visibility for us . So , uh there's one in January 2021 . I read only access to the veterans . I've mentioned this before . We are required to provide access to the uh service members and the veterans . It will not be the full access granted to other users like health care providers , epidemiologists , they don't need that . They need access to certain parts of that Isler like their deployment history and their individual exposure summary . So as I mentioned before , we are , we are on track to , to , to get that functionality built . Then , uh we have to do uh every two years , we have to , uh we got the G I O coming in every two years to look at the effectiveness of the Isler again , a third party coming in which is fine uh to look at uh how good is the Isler essentially ? How good is the data ? How , how effective is it with the intended purpose of why we built it to begin with August of 2022 the , the sergeant first class Heath Robinson Pact Act . We've talked about that and a lot of provisions in there as to how the Isler will support the implementation of the Pact Act and particularly again accuracy of the data collected . So I'll put out a plug for anybody representing a service out there . And if you know your personnel service accountability , folks by chance , uh put in a plug that the accuracy of the data that they provide to defense manpower , data center I E D and DC as to where the service member was located at . What deployment site when is so critical to populating the Isler . You were at this fob , I had this environmental assessment or incident report conducted for that fob while you were there . And then that's what I used to populate your Isler . And that's what is used to help inform the , the uh the business over on the va side as well . And then December 2022 we've already talked about the , the capability assessment and there's a big one there about the feasibility and advisability of linking the Isler to the E hr Yes , it's advisable . Yes , it's feasible and we , we will be working that and hopefully have that functionality right now . I think we're projected to have that functionality by the end of the year , which means the is the , the uh the , let's just say the health care provider , you're in Mh S Genesis because that's what you generally have open . When you have a patient in your office , you're in Mh S Genesis and you need to pull some exposure information for that patient to inform the medical encounter . You will be able to do that via the E hr and not having to get out of the E hr and back into the Isler . That's , that's our vision of how we're better , better trying to support your use of the Isler during the medical encounters . Next slide , please . So what is the , is , I guess I could have started that one first . But I think , you know enough by now , you've heard enough by now for me is a longitudinal record E P supports EPI research supports clinical care , supports medical surveillance supports disability claims , creates exposure cohorts so that you can do EPI studies health effects research . So that's , that's a quick summary of what the Isler is intended to do at a full deployment capability . And of course , once we get the uh MH S Genesis Isler integration , we'll achieve that uh even greater functionality with the Isler . Next slide please . And this is where uh I this is how you can directly assess it . Uh You can o over there on the left to get an E account . And there's some information I think in these slides that shows you how to get an E account . And then you can get access to the full capability , searched by individuals , searched by exposure location and health effects . You can get all that information with the , with the uh direct Isler account . If you don't have an account , don't want an account , you can access iler information , the the individual exposure summaries through the joint longitudinal viewer . And we know that is used a lot because we are able to track the number of hits if you will of people using the J L V to pull that respective expo individual exposure summary , a lot of use with that the capability . And then of course , as I mentioned , the future integration with the electronic health record . And I think uh Larry , you can correct me if I'm wrong . But towards the end of this year , we expect to have that . All right , next please . That's why um this is uh the individual exposure summary . I know you can't read that slide . Larry will demonstrate that , but we get 11,000 queries per day uh using the actual application I E going into or via the joint longitudinal viewer . 11,000 . I think it's up to 13,000 now per day where users are going in after these exposure summaries , which is good for us . And then we have over 5.2 million of those summaries in there . Uh Based on deployment information we have , if I hear I have no information on uh Lieutenant Jones or whomever being deployed , that that information will not be in the either . So it's critical for the personnel accountability , uh officers to accurately report where these troops are and when and you can get a , you can get a copy of the completed airborne . Has an open burn pit registry questionnaire via the island as well . Next slide , please . I'm not gonna get , get into the details here , but we phase this in . Here's the Isler version 2.1 dot 00 . That is what is live today and these sprints , those are just development cycles where OK , developers do this , get this done so we can get it out and test it . So there's a lot of uh a lot of detail there , but I'm not gonna go over each and every one of the sprints . But again , uh what we're at the 2.1 uh version today life please . And where we're headed is version 2.2 and that is the next release . And I believe Larry that's coming out on the 21st of April and the big thing there is we're going to be connected . One of the big functionalities we are achieving at that point is connecting with what's called doors H C defense , occupational environmental health readiness system here in conservation . That's a long word . And what we will be pulling from the doors H C is any significant threshold shifts in the audio grams of that service member or veteran . So that'll be a good use of pulling in uh threshold shifts that might be related to obviously a noise exposure or something else . And then the ad hoc reporting , that's the uh pilot going final with the ad hoc reporting that allows uh support uh where the epidemiologists and others can uh do ad hoc reporting via cohorts so good functionality there as well . And then these are the sprints that add additional functionality like I said , uh well , 30 June , we're at full deployment capability , but we're not done . Uh We will continue to work with the E hr uh is integration and other functionalities that are identified . We have a standing dod D A is steering group that's composed of representatives from the services , representatives from uh the va side . And those are places where we uh look for ideas of new functionality and of course , user feedback . Uh We're getting many , many more users feedback from the user community as to what , what is working , what is not what we could uh consider doing it be very important to us . All right , with that said , next slide , please . All right . So Larry is going to take it over from here and do a live demonstration . Uh It'll be quick because we're gonna , you know , we got about 28 minutes left . We gotta have some time at the end for a panel discussion , but Larry is gonna give you a good quick look at the various functionality as far as individual location , exposure and health effects . Search over to you , Larry . Thank you , sir . Um Hopefully I've taken control of the screen so everybody can see my screen . Can I get a confirmation on that ? Looks good , sir . All right , thank you . So , what I have here is just , it's our Isler dashboard . I'm not gonna spend too much time on this , but I just want to give you an idea of an overview of what Isler does uh from a technical standpoint and just a size standpoint . So I'm demonstrating this out of our production and test environment . So all the information that you'll see regarding the exposures , health assessment and , and any clinical data that's available has been sanitized or it's it's real exposure data . But the P I I for that has been sanitized . So we can't tie that to a real individual . We use AAA truncated and uh sanitized personal data set . So uh no risk of , of any type of , of data breach here . So we pull in data from various sources . Uh is what's been mentioned . Our primary source of exposure comes from doors I H the industrial hygiene model uh module as well as the military exposure Surveillance Library . Uh From here , we also get uh some health assessment data from the Armed Forces Health Surveillance Branch . We get clinical data from the N D R . This is la uh legacy clinical data that goes to the E hr uh from D M DC . Uh We get the location data where individuals are at . Uh This comes from the contingency tracking system , which is really a composite of about 15 different systems . And we get declassified location data from there . And then from on the va side of the house , uh we tap into the diff uh various registries , the Gulf War registries and the burn pit registries . So , you know , at a high point , what Isler does is it uses a , a Geof uh mechanism to take that location data and then goes through and compiles that for the known exposure data , the health assessment data and , and anything else associated uh with that location information and then puts that into a uh consolidated view . So uh just to give an idea of overall , again , this is a smaller set of data that we're using . But when you put it all together , Eyler has over 61 million records that we're pulling together and compiling . And if you start to break those through the fields , you know , we're talking into the billions of different types of data elements that we're pulling together to put our information um on the screen . So I'm gonna walk through the functionality . The first functionality is uh the search by individual , you know , that was our first big challenge to take a individual information and tie it to their exposure history uh from the different sources . So this is what's used by the primarily from the V VA as well as the clinicians , uh the va and dod clinical providers . Second functionality . We start to get into the more of the research side . The location search by location . That was our first challenge . It was what occurred where and then who was there ? Our third big rock was the search by exposure that is now taking the hazard or the exposures and then reversing that searching on that to identify all of the locations of where that particular exposure occurred . And then also again , who was there ? And then the last one is where we start to use the clinical data . This is where we get . Uh we use the I CD 9 10 codes C P T codes and other information to start looking for those health effects or those health outcomes that occurred . And then the exposures that are related with that and then if possible identify individuals um with those health conditions and there's uh those common hazards . So I'm gonna jump right in just to do the search by individual . So as a is going through what it's doing , it's actually going through and mining the different sources from D M DC . Taking all of that location information that's available to include self reported information that comes in from the uh the pre ID health uh deployment um questionnaires as well as any of the self reported information on the registries . It takes that and now it's starting to pull information in from doors . Uh I H uh Mel and the other data sources I already mentioned . And again , using that GEO fin . So if we start to break this down , um and , and going from a , a macro to a micro level , the first item that it pulls in is the periodic occupational environmental monitoring summaries . Uh To give you an idea of size , this puts the individual within uh you know , as close as possible about the size of a small town . Uh This is these are summaries that are done over a course of time . Uh Usually a long period of time . Uh They can be very long and lengthy . But what we've done is we've taken those down , broken them down into short small bite size pieces that present nicely on the screen . So what a what a poems does is provide uh provides the user or the reader uh short and long term health concerns that may have occurred uh have chronic effects uh from that vicinity and then it starts to break them down into the different uh exposure pathway if you will , whether it was air water , uh diseases , animals , et cetera . So you can expand on that and provides information about what the health risk is , unmitigated health risk , estimate , the control measures that were in place and any residual health concerns associated with that location . So for this one , for example , we have all of this that is presented on the screen . If you were to , we can download the PDF here . But if we were to pull up that PDF , it's actually it's a 24 page document . So the next thing we have on here is again going from the , the macro down , this is the exposure pathway . These are oasis . So if we're talking about uh geographical and Geof uh a poems being the size of a of a small town , an exposure pathway gets you within that block , it gets you within 100 m give or take of that exposure event . So from here , we use the military exposure guidelines to weight the different exposures of what was provided . I can filter on the items that are just on high and provide you a brief summary of what that expo that hazard was the exposure pathway of how it was trans uh transferred . And then any other information that's available for it . So for this one , for example , uh I have two different things I have . The first I have the sampling data that was provided for that water sample . So you go through and it tells you it has the bar code for the the sample , the date it was taken the sampling point , everything that was tested the results and the standard used . And if there's anything that's in exceedance , it would actually be highlighted in red . Uh In addition , I mentioned the attachments , attachments can be anything anything that the um the preventative medicine uh personnel felt the need to put into this file . It could be uh a scan document , it be handwritten notes could even be a pitcher , but I provides that to the , the user um in one screen . So from here we start to get into the registries , the registries , the self reported information , uh anybody who's associated with a registry , whether it's the dod or VA registry , that information would be here . So here , I'll just focus on , on the Gulf War registry . I'm sorry , on the burn pit registry . So if I were to click on this , it provides me the information about the registry itself and then if I click on here , it actually provides me direct access to that individual's questionnaire . So I can see the deployment locations . I'll go down , um , just to see the , the looking at the uh medical concerns or the item items that were self reported . Again , anything that was , uh answered in the affirmative on this one would be highlighted in red . And then again , going back to the incident reports to the exposure reports talking in , in terms of , of Geof fencing and size . Now we've gone from , you know , small town city block . Now we're getting into the incident reports . The incident reports are things that are newsworthy , uh uh the sulfur fires , you know , things of that nature . But now you're starting to get from , from 100 m down to the incident itself . So these are items where there's been some type of study , they've collected a roster and they have those individuals there . So again , if I were to , to click on here , what it actually provides me a copy of is the uh risk communication that was sent out to the individuals that are associated with that uh that incident . They're moving to the industrial hygiene . These are things that are very similar to the oasis . The only difference is now we're getting to again , go from AAA Town city in the vicinity . Now you get somebody who is in that room , you get into the size of a , of a small parking lot . Uh These are the industrial hygiene , uh surveys that are done or the studies that are done . Uh From here , I can expand on this provides me uh more information about that individual or that specific hazardous event . Uh and any of the controls that may have been in place . And I'll demonstrate this a little bit more when we start looking at the research side of things . And then finally , we get down to the , well , the health assessments . This is the information that is provided by the individual from their , their annual health assessments , their pre posts health assessments to include their , their reassessments . So from here we , what we do is we highlight anything that's in the affirmative . Typically , these are , are summaries of the work that was done or any health concerns that they may have had . And then lastly , this is again , this is starting to get into the wearable devices . This is what we've done in support of the N D A A section 7 34 blast and overpressure study . Uh For here , we present any information that's associated with a blast event . For this is uh a wearable device that was taken uh while they were in training specifically in this case in Fort Linwood . But it provide you all the information associated with that gauge that that individual was wearing uh for that period of time . Uh And it highlights what is the mac uh max peak acoustic pressure value and the max peak , non acoustic pressure value . So if I were just interested , click on this , it shows me everything associated with that gauge . If I was only concerned about the the spikes , I could click on this . And so this is a view that's used primarily uh by the V B A . Uh What they do is once they uh get a toxic exposure claim , they go to Isler , they generate a PDF of , of this um this view uh this PDF , for example , everything you've seen on the screen that fits on one screen , if I were to generate this , it , it's 73 pages . However , it's a lot of information to digest by a care provider . So what we've done is we put in this filter that allows people to focus on perhaps the medical conditions that are being concerned if somebody were to come in and they were concerned more about the respiratory issues , you need at least three words , uh three letters , but I can start typing uh respiratory . And at what it does , it will only highlight those exposure events that are associated with respiratory issues . And kind of the idea is to to clean that up a little bit . So it's not as much information and overwhelming uh for the care provider . Uh Moving on , this is a search by location . Uh This is used by researchers and policy folks . Uh and , and a bunch of different user types . The idea being that um you start to look at a location , you want to know what happened and occurred where or maybe you have a specific event involved . So if you were doing a study or you had concerns about uh an event that that took place , you can go through . I'm gonna do a research for um for the F-16 crash that occurred in Jordan in 2014 . So if I wanted to build a list of everybody who was there , put in the information , I'm gonna just tighten it up to put in a , a date range . When I hit search now , Isler is going in different directions . It's using that GEO information for that location , putting it to a name tile to get the , the coordinates and then pulling together all that information regarding individuals who were there and any of the events or the exposure , events or studies that were done during that period of time . I apologize . Usually this is uh our , our average query time is about 100 and 15 milliseconds . So I'm not quite sure uh why this is taking so long , but there we go . So what it's done is , as I mentioned before , it's pulling all that information from D M DC , just make this a little bit bigger . So it's easier to see . Uh it has the poems that are associated with that has the exposure pathways during that time . And then it has from down here , I can pull open uh actual incident reports that occurred there . It's very similar . If I were uh more concerned about the V O CS and go from here , get , get that information . But then if I wanted to build that cohort that population study , if I was concerned about health effects that occurred during that , that crash and the recovery of that crash , I could expand this out . I don't know why this has taken so long from here . I can go through and build a cohort . And what it's gonna do is give me all the pertinent information that I request for uh for this . So for essence of time , I've gone ahead and I've downloaded uh this cohort . So as you can see here , I've gone ahead and blacked out the names of on there Um But again , and these are sanitized E D IP I s but it gives me all the information that I would want if I could uh have a study . So for this , I just did gender date of birth service uh service component if it's available will be uh listed as well as the MLS . And from there , uh our first challenge with the research community was to provide them access to the data so they can export that out and have that in their own systems . What we're building now uh Mr Jones referenced the ad reporting capability . We're building out actually a tool that you can use within e to get into the discrete data elements and slice and dice that information . So for example , if you were doing a study for just navy personnel at that location , that may have had concerns about cancer , you could build that type of study . Righty sir . It's about quarter of and time for us to move on to uh the question and answer session with all of our other participants . This is Steve . Um I I can't offer up Larry to provide a , a full demo to each and every individual . Of course , but for if you have like a meeting , uh whether it's your surgeon general's whatever meeting or some other opportunity where Larry and his team and myself be more than happy to be placed on your agenda to uh further discuss exposures . And of course , the Isler . So that's a , that's a promise for me to you again . I can't do individuals because it's just too time consuming but we can do , uh , meetings , whatever it may be that you have , uh , scheduled down the road . All right , Larry , I'm , I'm gonna , are you looking at the questions or do you want me to ? Uh , yes . Sorry . I just pulled him up from the chat . Yeah , I , I think one that I have , I think I put it in there actually is how is a complete Isler built for SOCOM service members and others who do not provide unclassified deployment location data ? So sorry , I can take that one . Uh So we've worked , uh , I guess it's been probably about two years now . Uh We started working with the warrior recovery , uh specialists and analysts from the different services . Uh I , I know they have different phrasings and different names but at the end of each deployment , um or operation that they have with those individuals , they actually do a checklist that they keep locally . So we know what closures were there and they know where their operators were at . So they go through a process to put that together so that , that individual when they separate from service or whatever they need it for , they'll have access to it . So they don't have a , an A per se because we do use declassified data . However , they have the ability to , to have that same information . Available for their needs . Ok , thank you . Um I'll just uh add another one . Uh There was a question about how is blast exposure data captured and that's a good one because we're uh we're heavily involved in understanding the feasibility and advisability of establishing longitudinal blast log I E blast overpressure for these troops to fire what we call tier one weapons . Uh one oh five or 1 55 sir . Gustav uh shoulder fired , you name it . They produce uh blast overpressure . So very quickly on how that uh is from the gauge to the tablet to doors I H to is that , that's a , that's a very high level view uh of how it gets uh how it gets done . But yes , so once that information is entered into the tablet , it does get stored into doors I H which is serves as primarily a data warehouse . And then what we do is we actually have a near real time sync where we update uh our , our pools from uh doors I H every four hours . So once that information is is indoors , uh we go through our process and link it uh on the back end and present it with an is ok . Um Brian , do I have a time for two more specific Isler questions or do I need to move on to open it up for the panel ? Sir ? The floor is yours ? Ok . So a couple more Isler questions . Um One is how do I get an account ? Go back , there's a slide there . I forgot what number it is , but it's got the uh link uh go to that URL . It'll tell you what training you need to do in order to get an account . And then Larry controls access to the , to the uh uh account . I e verifies who you are and allows you in an account or not . That's it somewhere right there . Ok . Um Here's one , let's see for an individual , what is the , the specificity and reliability of the industrial hygiene events listed in Eyler as being significant ? And that this gets back to Steve Jones here again , uh this is very critical , the industrial hygienist or the industrial hygienist technician . It's very critical that when they , when they do their workshop assessment because it's required by law to do workshop assessments at certain points depending on what known exposures are in those workshops . It's very important for them to collect the right data . Q A QC , the data particularly samples that are pulled and analyzed Q A QC , that data before they enter it into doors . Because once the data from whatever source , from whatever individual , once that data is entered into doors , that's what the Isler will extract out . Isler doesn't do a cleansing or anything else of that data . So again , it gets right back to the grassroots of this , the individual entering the data , it's upon you to make sure that data is of sufficient quality because it will be used for many purposes as we demonstrated during this discussion today . Ok , Steve . Um , er , just make a comment about him just to the hygienist and , and really their focus was kind of the here and now when , when , when that sampling was done , um , you know , if that level is high , what can we do to protect the people there in that shop , you know , be through engineering controls or , or P pe or something . So , so um I guess just kind of keep in mind they , they , they , they weren't just doing sampling in isolation and , and , and then , then posting it , it almost always , if it was high , I almost always had um kind of an action afterwards . Yes . And I mean , entering the data is , is one part of that . I totally agree with you , Doctor Ching identifying what you can do for that workshop to advise that supervisor to mitigate the exposures that are occurring because that's the process in that shop . Absolutely . That's one of the primary reasons for those industrial hygiene assessments . OK . Um um Go uh Larry , go to the panel discussion question about whoever's got the , the slide . Uh So right now we've got about five minutes before I do a summary key takeaways and then we do a final uh closing remarks . So this right here is just opened up for anyone with any topic that we have covered and we'll spend the hopefully we can get a couple of questions in here . I cannot scroll all the way back up to the top of the chat . It's just too much , too much . So , if there are quick questions that someone wants to put into the chat right now , we'll try our best to get answers to them . Uh , before we start closing out . Um , I was , I was taking notes on some of the prior questions if , if you don't mind if I just kind of put out a few things real quickly . Uh One was on the toxic exposure screening and a um exposure assessment . There , there , there are two different things . Um I , I want to emphasize the screening . Uh There , there's about six questions that , that are asked in the screening and there's different kind of outputs if , if it seems like the veteran really wants to or should be putting in a claim or , or they have a presumptive condition , they're , they're kind of you , you'll lead in that direction too , but , but that um screening can be followed by an assessment . So , so , so there , there , there are two different things . Um Another thing too is um can I put in additional deployments ? So say you're um you , you , you're active duty , you deployed in 16 , you joined the registry when you right when you got home and then you deployed again in 2018 , the , the registry was locked . It , it was kind of a one time submission , but it's been configured to um add additional deployments for um those are on active duty now , you know , you , you deploy today . Um Are you deployed before you joined ? You just got back on your deployment . You wanna , you know , you , you wanna put that information in there and then you can , but this is only for the deployments , not for um you don't go through the health questions again , you know , you , you know for that . Um So , so , so those are two that I saw and , and , and we , we just kind of leave it for , for , for other questions now . Ok . Thank you , Doctor Ching . Uh one quick question because I think it's very relevant . Uh is uh well , Larry correct me if I'm wrong here , what will the , with regard to the Red Hill , the contaminated the JP five contamination of the water Red Hill ? Uh There's a question on um will those , will those members be tracked in a registry ? And is , and I can tell you there's already a registry . Well , there's an incident report , I call it an incident report . I don't want to get too far down the to the right with registry at this point . But an incident report that I think has 28,000 names in it associated with those who lived in the housing uh on the base there or elsewhere . The the dod controlled housing that their names are in an incident report . Larry , is that uh is there a plan to pull that into I or is that already established ? Uh It's so the , that's a two part question . So the information that's been approved uh within doors I H meaning it's gone through some type of Q A process that is already posted and present in I um but it doesn't cover all 28,000 . Um It , it covers a small subset of that . Uh And the reason for that is there are some people that are , are uh dependents for right now have not been approved to be presented in even though we have them for operation to um for Red Hill that they aren't in there . And there's also dod civilians that have been uh are on that list that have not been part of it . So , uh I'm looking right now in , in real time and uh as of right now , we've got about 2650 individuals um for Red Hill uh in OK . Thank you , Larry . I went down to the last three minutes . There's one quick question . I'll just say what I think for military members , should he or she always go to their military medical clinic to start or directly va for topics approached in this presentation , I would , I'm just going to as an old troop here . Uh If you have a concern about exposures , go to your primary care provider assigned to you within your installation and unit All right . Um We're gonna finish on time here . I mean , is there a key takeaway slide , Brian ? Are you pulling that up ? All right , the key takeaways is uh listed here . Um And by the way , we're very appreciative of your time today and very appreciative of your uh very good questions . I know it's difficult not to be able to talk back and forth , but that's the nature of teams and chat . But we capture all of your questions . By the way , we will use those questions . We won't be able to come right back to you and answer the question . But we will use your question to inform what we do as we go about in our respective areas presented today . So key takeaways again . Uh what is an environmental exposure ? I think you , you know that and I was trying to emphasize it's not just burn pits in a deployed uh place , but of course , that's a very significant exposure . But don't forget about the garrison exposures and the exposures during training uh airborne hazard and burn pit registry . A good uh uh review of what we have . And then of course , uh Doctor Ching did a nice job on where we're going because we take seriously the Nason report and the dod I G report , whatever report we get on on the registry , we take that seriously . And as he showed , there's going to be some uh revamping of that to better uh meet the intended purpose per recommendations from others . Uh Doctor Masters with the providers , you know , rely on your evidence based knowledge , expertise and skills . I think he gave a very good rundown on uh that itself within his uh presentation . So that's a good takeaway for you to rely on your own evidence based knowledge and seek knowledge elsewhere . Also , particularly do your best to get exposure information if it's a , if it's an encounter related to an exposure , uh , we talked about the Isler could take away from the Isler . Uh I could spend another hour on the demo but in the interest of time or not , I , I leave it open if you've got a , um , a meeting or something that you want an Isler demo , just let us know and , uh , we'll do that and then , um , uh this session was sorry , it wasn't on camera before I forgot to turn it back on . This session was also meant to show you the great amount of collaborative work done between the dod and va to take care of the service members and veterans and their family members . Uh , with regard to research , health care benefits , transition , support , outreach and education . That's the key takeaways . Um I guess Brian at this point , do I just , uh , wrap it up with the closing remarks ? Yes , sir . You can . All right , closing remarks . Uh We hope you enjoy today's event . Uh , the presentation directed at health care providers , highlights updates and initiatives related to environmental exposures . This event was sponsored by the DH AJ Seven Continuing Education Program office . So uh Brian and Katie and others from the what's called C O here in DH AJ seven . Thank you very , very much for making this happen because it , it took a , a good lot of effort , background work to make it go as well as it could say and all who wish to obtain continuing education , credit or certificate of attendance . Uh for this event , please visit . Uh There's a website , I think you already know it's in the invite the W W W dot DH AJ seven dash ce P O dot com . And uh I , I , I think that's in some of the stuff that you've already received . If you missed any of today's presentation , it will be offered as a home study activity starting May 15th , 2023 . Uh This May so , uh I'm not sure what a home study activity is , but it will be offered in case you missed it today . And then there was a question whether this would be taped , but I assume you can get it through the home study activity . And once again , uh we thank you all for your participation in today's event and I wish you uh uh the rest of the day , a good rest of the day and you've got our addresses , you've got our emails , I think based on the first or two or three slides , whatever it is . Uh I'm sure I can speak for everybody . Uh My colleagues here during this presentation , if you have a question , send it to us or if , if you need to talk , we can figure out how to talk . All right , Brian , that's all I have over to you to uh tell us we're done very good . Uh We are now finished with uh today's special feature webinar and we hope we see you again soon . Thank you very much .