Good morning, everybody. I'd like to go ahead and introduce Dr. Patel, he's a fellowship trained interventional and non-interventional pain specialist at the New Spine Institute. Dr. Patel has spent years helping patients resolve their acute and chronic spine and joint pain. He earned his bachelor's degree with honors in biomedical engineering from the George Washington University School of Engineering and Applied Science. After earning his degree, he attended George Washington University Medical School and earned his MD. During his medical school years, Dr. Patel worked with the Neuroendocrine Unit at the Massachusetts General Hospital and Harvard Medical School to publish multiple papers and conduct research on athletes in the Boston area. After medical school, he trained at the Albert Einstein Medical Center in Philadelphia for three years as an emergency medicine resident. Around this time, Dr. Patel found an opportunity to move to Tampa, Florida for an occupational medicine residency position at the University of South Florida. Within two years, Dr. Patel became the chief resident of the occupational medicine residency and graduated with a master of science in public health from USF. Dr. Patel has also completed a fellowship in interventional and non-interventional pain at the Duke Institute in Melbourne, Florida. At this position, Dr. Patel completed over 2,700 procedures, including hypoplasties, spinal cord stimulator placements, and other minimally invasive procedure. Through his education experience, he brings a unique and progressive approach to pain management and the management of occupational injuries. Thanks for that, Dr. Schrade. It's funny because when I was a resident, he was one of our presenters, so it's kind of weird that he's now allowing me to present in front of all of you guys, so thanks for that. Just a little disclaimer slide here, like we mentioned already, I'm an associate professor at University of South Florida, assistant professor at South University, also the College of Medicine. I work now at South University and LECOM, and lastly, the people who pay me is the Institute of the New Spine Institute here in Tampa. Gigi was one of our medical assistants, and she also helped me kind of organize this. She's going to be a LECOM student, too, so that's nice. I give this talk all the time for our occupational residents at University of South Florida, so my only objective is basically just to make sure that they pass their board exam, so hopefully these are some high-yield information and can kind of get you guys, not to probably pass your boards because you're probably over that, but more importantly, just to learn some of the new information that's going on, so that's it. And I normally jump right into it, so I don't like to put like educational slides. I like to just jump in, all right? So this is a 46-year-old chemical engineer who presented with nausea, vomiting, fatigue, extremity paresthesias, and dark brown urine. I try to make it interactive, but I know it's early, so does anyone know what the next steps would be here? Yeah, I don't know, right? More is for good, so exactly, and that's what I try to hone in on our residents here, you got to get a true occupational history, occupational exposure, and things of that nature. The majority of times, they'll say, get some labs, and so this is what we do. The patient then started to develop hemolytic anemia, jaundice, and then renal failure, subsequent renal failure. So Moe's asked, what do you think this guy's occupational hazards were? Yeah, well, so let's just say he worked in a manufacturing paints. Any of these kind of work exposures kind of could have caused him to be exposed to a certain heavy metal. A lot of times, semiconductors, electronic device manufacturers, usually on the examinations, it's this parish green color that they always mention. Environmentally, there's a few cases of where there was, I'm going to spoil it, spoiler alert if you're playing, but it's arsenic. So in Bangladesh, and there's contaminated wells that have been linked to this as well. So now comes the dry slides. The arsenic poisoning is typically broken up into three oxidative states. The most dangerous one is the first one here, trivalent arsenic. I just took my boys probably like five years ago or something, and that was one of our questions was regarding which one of these is the worst. Then there's three chemical forms. There's the organic, inorganic, and then the arsine gas. The bottom two are the most poisonous, and we'll discuss those. The organic, there is some bioaccumulation that can occur in fish, and we'll discuss that in a few slides. But usually the top two ones that are tested are inorganic or arsine gas. We'll get into arsine in a second. The main thing I try to hone in on patients is if you know what the heavy metal does, like in general, then you can kind of predict what the physical exam findings or the presentation will be. So in arsenic poisonings, typically it's cellular energy depletion, and it typically targets high energy tissue. So when you look at that, you can kind of say, okay, well, what cells in the body are high energy? And this is exactly what you look at, like GI tract, your bone marrow, things like that that typically have a high turnover. Those are the things that arsenic are targeting. So usually these patients present with GI upset, bloody rice diarrhea, bone marrow depression, as we talked about, like the hemolytic anemia. Cardiac eventually can lead to hypotension. Torsades is a huge EKG finding. And then neurologically, they have the burning and numbness in the feet and hands. As you notice, in the acute setting, there's not really any kind of motor deficits. There's not any kind of true neuropathy. There is neuropathy, but not any kind of motor deficits. Now, once you get into the severe cases, that's when you start to develop the ascending weakness. They say it's very similar to GBS, Guillain-Barre syndrome. And then as it gets a little bit more chronic and chronic, then you start to develop what is always a buzzword on board exams, is the peripheral vascular gangrene, or the black foot disease. Usually, I think in our case, they actually presented a picture of it and said, what was this person most likely to be exposed to? And then, obviously, the cancer, squamous cell skin cancer is huge, too. There's only a few heavy metals that will cause cancer, and we'll try to hit each of those and determine what specific cancer is related to each. So in this one, it's typically skin cancer. Management, typically, it's a diagnosis that we worry about. So you get a 24-hour urinary excretion level of arsenic. Treatment, you're going to see a very continuous trend in each of these heavy metal exposures. It's going to be very, very similar. So it's removal of the source, volume resuscitation, gelation, and potentially hemodialysis. By the time you get into hemodialysis, you're having pretty severe organ damage, or you're having inability to return the patient back to their baseline. And I put these pictures on it because these are typically clinical findings that you would see. Torsades is the one down here, which basically, by the time you see that, it's a problem. And so it's not going to be reversible with just a simple magnesium. It will help you stabilize the patient, but the key is to really get them to hemodialysis by the time you see that. All right, so new presentation, somewhat. 46-year-old Dale, who works in a semiconductor manufacturing, presents with this garlic-like odor at work. His lab work shows some massive intravascular hemolytic anemia, and then eventually leads to acute renal failure from acute tubular necrosis. So in this case, if you look at the bag on the right, it represents the plasma that's removed. So as you can see on the left side here, it's a little bit darker. On this side, it's a little bit almost orangey shape, and that is something from an arsine-poisoned patient. So on the left is the normal and the right, abnormal. So this is similar to what we were just discussing. The presentation's very similar. However, the three buzzwords that we usually, or four buzzwords we usually get to is abdominal pain, hematuria, and hemolysis. The combination of those three, you should probably think of arsine gas. I don't know why, but they love asking about the garlic-like odor. I try not to get too close to my patients to smell them, but if you did, they would smell like garlic, I guess. I don't know if you guys teach at med schools and stuff now, but for, so you've probably seen this. A lot of the students are coming back with these image, like picture, like they're called picture something. So basically, instead of having three or four pages of notes or whatever, they just have one or two pictures. So I found this in one of their books, and I found it kind of cool because it's like five or six different things that are linked to arsine gas in just one picture. So it's pretty neat. I mean, I wish I could draw, but that looks cool. All right. So this is a new patient. So after a, well, three new patients, after working a shift at a local automotive plant, three middle-aged men complained of pain, paresthesias in the feet, and they all presented somewhat looking like that. Let's see. What next? Well, I'll just tell you because it's a little easier, but after 10 days, the symptoms progressed to pain and numbness in the lower extremities in the hands. So aka distal extremities. And then even the weight of bedsheets became unbearable. So they're having severe aledinium. This is a rapidly progressive peripheral neuropathy that we're talking about here. And the sensation is typically predominant in the feet. So this is thallium. And usually the picture's going to give it away. It's this development of this hair shedding that arises from the different parts of the growth of the hair. And it causes thallium kind of attacks it in those different stages and causes that thinning appearance. And I'll tell you, under a light-powered microscope, which you probably all have in your office, right? Sorry, bad joke. But basically you can see the darkened hair roots. And that basically is like the key sign that patients have thallium exposure. By the time they come to me, their EMGs look a little wonky. They've already had a 24-hour urine. And the key for these patients in the acute setting is a two-step process. You could use the Prussian blue. I Googled how to say that yesterday because I kept screwing it up. But it's Prussian blue. It's basically excreted in the fecal matter. So that way you can try to get rid of the thallium in that regard. Just to make sure everyone's still awake, I'm just going to do a quick question. So potassium chloride and Prussian blue have been used to treat what acute intoxication? B thallium, correct. No, I'm sorry. Can you repeat the question? Yeah, of course. I'm sorry. So the question was how are patients taking in the thallium? And there's no real mechanism. You could just be exposed to either respiratory, you could have GI contamination as well. But the way that the treatment options work is through potassium chloride and Prussian blue. They basically create compounds and it's excreted in the fecal matter. So it's just kind of absorbing it through the GI tract and binding and then being excreted. For potassium chloride, it's actually excreted in their urine. So it's a fun little question that sometimes shows up. But usually the fecal matter is the fastest way to get it out. It's a good question. I'm not sure. Do you know? I don't know either. The question was how is thallium used in the automotive industry? And honestly, I do not know. I just know. So next, this is a pediatric case. I use this one because I want to also not rule out kids aren't working, but I want to make sure that we also know that there's different levels of contamination here. So this is a 14 year old with bilateral thigh pain and started to become a hermit in the last few weeks. On examination, the child has profuse sweating, tachycardia, hypertension, tremors, ataxia. It has this rash that's almost like scuffing of the skin on the toes, palms, and fingertips. So when I first saw this, I thought maybe like a TENS or a Steven Johnson syndrome. And then we started to get more information about what was going on. And the child had ingested mercury, which you don't see too much of anymore. But the key is to have your radars on for some of these cases. So there's three forms of mercury. There's elemental, inorganic, and organic. OSHA has guidelines. I don't think these have changed in the last few years, but I always try to keep tabs on it just in case. But these are the OSHA guidelines, also the BEIs of what each level should be, especially in the urine and the blood. So in this acute setting of elemental mercury intoxication, the concern here is GI upset, cough, pulmonary issues, kind of like generalized, just not feeling great. So these sometimes can go under the radar for a long time. I was having this talk, and one of the residents asked, well, this is what we see every day. And it is, right? The key is getting a real good history and a good physical examination. Because if you see any of the other things I mentioned, that's what we're looking out for. Now, in a severe case, people will start to get just acute respiratory distress, will start to have renal failure. So heavy metals love the kidneys. And so if you ever see any kind of kidney issues, one of the first things that you should think about in the work setting is, were they exposed to any heavy metals? And as long as the answer is no, then continue. Continue your regular workup. But usually there's not many things other than occupational hazards or heavy metals that cause severe, progressive, and acute renal injuries. And so in the chronic setting, by the time you get to this point, you get Parkinsonian-like syndromes, incoordination, and then fine motor and tension tremors. You can get acridinia, which is the painful and pink extremities that you saw in that child. You can also get muscle MSK issues where there's proximal weakness. So this is an interesting notion. But by the time you get to this level, this is like notoriously tested. But this is the part where, you know, patients start to get mad as a hatter and all those kind of situations there. Now, the management is very easy. Well, not very easy, but it's similar to what we've just been talking about, right? Removal of the source, chelation, and then hemodialysis if necessary. So I'm going to stop with the treatments for most of these because it's pretty redundant. However, the key in this is the diagnosis. So you would see this increase in catecholamines. And that increase in catecholamines actually leads to hypertension, the sweating, the tachycardia. And especially in children, it can go under the radar and sometimes diagnosis fetal chromocytoma. The key is to check the 24-hour urine. If I haven't hounded this enough into your brains yet, remember, if there's a kidney issue, you're going to see it in the urine. You're going to see it on the blood of, you know, acute kidney injury. So that's what we usually look for. Now then there's the inorganic mercury, which is very similar to the organic components that we were just discussing, but there's a more prevalence in GI absorption, so the patients will have more GI kind of issues. So they'll get to the point where they have severe nausea and vomiting that leads to hypovolemia. The other thing is they have these hyperpigmentations, the gray-brown discoloration of the skin folds. So those are unique to inorganic mercury. Once again, they can cause kidney issues. The mechanism is slightly different, but once again, if you're seeing kidney issues, acridinia, any change in mentation, think of mercury. Diagnosis is the same, and then treatment is pretty much the same. Now, organic mercury is pretty interesting because there is this thing called bioamplification. So if people have seafood, if they're intaking a lot of seafood, they can have bioamplification of it. And this is mostly GI absorption. And the key thing here is that it can actually go straight to the brain. So organic mercury, we always worry about neurological problems. And usually, this can reach the brain much, much faster than any of the other mercury components. And in the chronic setting, you can also have mental retardation and offspring. So that's a little different than all the other ones that we were talking about. All right, so same here. So we're just going to go to question number two here. A worker with chronic headaches is referred to your clinic by primary care because of elevated levels of arsenic on general metal blood panel. What's your next step? Don't forget, I keep talking about urine. So it's actually C. It's urine test for inorganic arsenic. And then also ask the patient to abstain from seafood for two to three days. Now, let's ask the question. Seafood and shellfish accumulate arsenic through something called arsenobatadiene. It's less harmful, but it does cause artificially inflated levels of arsenic. You'd have to consume a lot. And to be honest with you, it's more of a rule out. But if you see patients with inorganic arsenic, remember that's pretty confirmatory of exposure. What else? Yep. So now you have a 30-year-old battery maker with neuropsychiatric disorder with ataxia and tremors. Which of the following is most likely to cause? Yeah, that's right. Where'd you guys go? Johnson Battery or? Hey, right. Johnson Controls. That's right, man. Sorry. Yeah. Yeah. We used to do that for our little tour. So it's nice. All right. The answer is A. I literally gave this talk like six weeks ago, and one of the students said, well, you haven't talked about magnesium, copper, or chromium, so it's got to be A. So I was like, that's pretty fair. Anyways, we hit mercury a lot. And then regarding mercury poisoning, all of the following are possible sequelae except for D, hemiparesis. They're not related. And oh, sorry. One more question. Central nervous system dysfunction associated with organic mercury exposure includes all of the following except... No, they don't give you a fork, right? We'd have a lot more people licking fish and stuff, right? Like, that's right. Yeah. So it's usually the other two are more likely to be associated with mercury. Wow. That's a lot of questions, huh? All right. So which of the following agent is most likely to cause stimosis, gingivitis, and tremor? Yeah. This is the mad hatter syndrome that we always get tested on on our boards or whatnot. Yeah. And then usually the behavioral changes is what they're hinting at with the mad hatter syndrome, if you will. And we feel like hitting that a lot. I'm just going to keep going. Does anyone need a break or anything? All right, cool. Nope. Do you need a break? No. No. There's a question about the automobile industry. Yeah. Yeah. Interesting. Interesting. Oh, I have no clue. Honestly, I don't know. Yeah. I'll be honest. Sometimes I never know because I used to work in the area. By the time they get upstairs, like you just hear about it, you know, and you don't really get to follow up, but I don't know. Yeah. They used to be in the actual thermometers, right? Like, yeah. Yeah. I felt like they stopped doing that. Really? What? Depends on what order, you know? That got fun. All right. So this is a 45-year-old manufacturing worker with fatigue, irritability, abdominal pain, and constipation. His wife, like my wife, probably said he had some difficulties concentrating too. And on examination, he has wrist drop, foot drop, and motor neuropathy. So the next step is where does he work, right? So battery plant. You guys were just there. Crystal glass makers, firing range operators, shipbuilders, lead miners. The answer's in the last one, right? I apologize. This is probably not the best. You can see them, like, right in there too. And then you can kind of see them through the teeth. I think they're mostly in the teeth, if I'm not wrong. But, right, there's some gum. It's a gum line. Sorry. So this is probably... Okay, thank you. Yeah, you can see that there. In the gum line. Okay. So here's what happens in this situation. And, you know, the key take-home for lead is that they develop peripheral motor neuropathies. And so unlike the other ones that we talked about, where there's just neuropathy, this is a motor deficit that you're going to see. So you're going to see the wrist drops, the foot drops, and things like that. And that's usually caused by the strong cell destruction that leads to demyelination. You see this on EMG, you probably missed the boat on it, you know. But it's something to kind of keep your radar up, especially when people come in complaining of these things. I've seen so many MRIs that are done that are normal EMGs that obviously will point towards this. But, you know, the key is to catch it early. What else? Let's see. Usually this is... We haven't talked much about reproductive health, but this causes infertility and low birth weight too. So this is usually a hot topic for some of our board examinations. And usually the diagnosis is unexplained hypertension. That's actually been a huge part of how some of these get detected in screenings, is that you'll have like a 30-year-old with, you know, 190, 200 systolic, and you're just like, what's going on? So anytime you have an unexplained hypertension and you can't kind of write it off as non-compliant with medications or family history or something like that, think about lead, especially in certain industries. And the way that you test for it is just get a venous blood. You can get a CBC with a... But usually you'd have to get the blood lead levels too. Treatment, obviously the same. There's different criterias of how to medically hold somebody back from work. Also when to chelate, when to do what's called hemodialysis and things like that. And we'll get into that in a few slides. But the key without having to remember all of these kind of breakdowns is that lead blocks certain enzymes. And so these enzymes cause an increase in the proteins behind it. So you'll have a huge increase in BLL, ZPP, and EPP. So if you do a blood test, you'll see elevations in this. And where are we at? Yep. So I call this power of 50. So usually I try to come up with simple ways of remembering certain things. And this is my way of remembering when to hold people back and what the OSHA permissible levels are. And so I do not think this has changed. So correct me if I'm wrong, but I think this is still the same. But usually medically removal, if they have three tests that are greater than 50 or one solid test that's greater than 60. We talked about this a little bit, but anytime you want to go into hemodialysis or removal using chelation, it's usually 70 and above. So I remember 50 is like the main take home and 61 time. And then 70, there's some problems there until you go and get it out as soon as possible. And then usually the next question is like, when can they go back? And basically you have to wait until it's less than 40 and you have to recheck it every two months or so to make sure it stays below that threshold. There's a huge movement now with these areas where children are being exposed to lead poisoning in old areas. I think we've done a pretty decent job of getting out of the gas and out of the paints, but there's still children who come in with abdominal pain, constipation, fatigue. They have mental retardation or mental slowing. And this is a risk that's not just in occupational world, it's also in pediatric. So I like to kind of make sure that, you know, you know about that too. Sorry, there's a lot of breaks for students. Yeah, of course. And we talked about the CDC's limit for children. I actually looked it up yesterday and it had been changed from five to 3.5 and up forward. So the CDC wants it to be, you know, anybody outside of two standard deviations is flagged as abnormal. So it's looked at every four years and the reason that it was dropped from five to 3.5 is because the national means are dropping. So this is the standard deviation is growing. How many water systems, I mean you think about Flint, how many water systems still have issues with lead toxicity? So that's a lot. I mean, we've got aging infrastructure, a lot of them in these valleys that these water pipes were put down, you know, decades ago. In Milwaukee they added some phosphate to the water supply and the phosphate does oxidize the inside of the lead water pipes. So you get a thin layer of lead oxide which kind of seals off the rest of the lead inside the pipes and that decreases some of the lead exposure to the water pipes. All the old cities, if you keep the gauge balance proper there, there's not lead in the water. It's all about maintenance, not evasion. Yeah, kids read anything right now, right? Kids read whatever, you know. To your point, there's not lead in paints other than an industrial setting. Well, we just moved down here in Tampa and they were redoing the entire paint, like they were painting the whole building and they hadn't painted the handrails in probably decades. And it's such a small thing that they had to repaint, but they had to give out all these flyers because they were like, hey, make sure your children don't need any chips because they haven't probably been replaced since the building was built. So, you know, you just never know. Yeah, sorry. That's interesting. Oh man, that probably turned out to be a costly adventure, huh? Yes. All right, so the next thing I want to talk about is a 54-year-old male who works in a metal plating position. Comes in with shortness of breath, chills, and muscle pain. Hangover? What's that? Hangover? Yeah, it's a fun fact. I wrote this slide here before COVID, and now every time I do this talk, everyone's like COVID. I'm like, sure. And then pulmonary edema started roughly one or two days later. COVID, right? COVID, right? So since it's heavy metal, it's cadmium poisoning. This is one of the things that is notorious. There's three stages, and usually it gets progressively worse as the patient ages. And usually in the beginning stages, it's just the mild renal tubular dysfunction, surprise, right? Then there's a decrease in bone mass, and eventually they start to get severe kidney issues. And we'll talk about why it affects the bones in a little bit in like a slide or two, but then you can start noticing these pseudo fractures. And then by the time it gets to a serious phase, they not only have this like fractures of the spine, but they also develop this like almost abdominal girth here. So it's pretty noticeable. I'll show you some slides of it. But I see this in my practice a lot where we'll have like a 77-year-old person who comes in with these acute fractures, and they had cadmium exposures decades ago. And so it's a progressive kind of thing. Usually osteoporosis is notorious after the age of 70, so we just assume that it's from that. That's right. They always catch up to you. So usually these are people who work in metal alloys, nickel, cadmium, battery packs, PVC. There is an environmental, well, you know, contamination of rice in Japan that people kind of talk about. But usually these patients present pretty much like COVID, right? Cough, shortness of breath, fevers, chills, have some musculoskeletal, random pains. But the key here, and this is the take-home message for cadmium is that if you have a patient who has the potential to being exposed and is a smoker, you have to tell them to stop because there's a link to transitional cell carcinoma of the bladder with people who smoke. And so that's something that always shows up is just to make sure that if they're smoking and in these high risk occupations you want to make sure. That's interesting, I would never have thought. But there's also one other thing and I just mentioned this because it always shows up as well is testicular necrosis. How often do you hear that? So anytime you hear those buzzwords, think of cadmium. I guess Master Lock didn't want any of that. Yeah, but they've changed too. My problem is I forget the codes, the combinations, and then I like got thrown out. It's the most indelible in my brain. That's fair, that's fair. It's like the cell, it's like the phone numbers, right? Like before cell phones, I used to remember everyone's phone number. Now I forget like immediately after you tell me. So ACOM has released some of these heavy metals. Every so often they'll do like emerging trends, if you will. And so cadmium has been on their radar for it. There's another one, beryllium, which we'll talk about at the end. But yeah, it's strange because you'll see these like cycles of things that come and go. Like for a very long time we didn't hear about this and now it's coming back. The bladder cancers and things like that. So there are safeguards and as long as the companies that you work for are being appropriate about it and managing and doing the appropriate testing, I think it protects the workers. But you know, it doesn't matter if the employee or whoever is not going to be compliant, you're still going to run into issues. So I don't know if all of you guys, well some of you guys work in the workers comp world, but I always say that you should tour the companies that you work for or that you kind of sign up for, if you will. Because before you even see any of their patients, you could point out some of their faults, like some of the faults in their systems. And that will indirectly kind of decrease your amount of patients that you see, but also keep your workers safe so that they'll treat you better when they do see you. All right, but another thing about cadmium, this is so there is hypercalcemia, there's calcium in the urine, but there's not calcium in the blood. So patients always say, well, if you're losing bone mass, there should be calcium in the blood and there isn't. And the reason is because there is, cadmium creates some kind of connection. There's, I'll talk about it, but it basically combines the vitamin D that usually helps to absorb calcium in the urine. And so instead of absorbing calcium, you're actually just excreting it out. So these patients will have a very high level of calcium in their urine. Also leads to osteoporosis and osteomalacia. And that's the reason why they get these pseudo fractures is because the calcium is no longer being absorbed by the body. It's just getting kicked out. What else? Stop smoking. So all right. So which of the following is the earliest effects of chronic cadmium poisoning? I find this question to be silly because it's earliest of chronic, right? But yeah, you have proteinuria, mostly because I've been talking about urine all this time, yeah, that's right. You're only going to remember the one thing it's like, it's in the kidneys, right? So yeah, I think we've hit that enough. All right. This is a long one, but a 60 year old male presents your clinic complaining of fatigue, headaches, says he can no longer taste food or smell, right? Or smell coffee brewing in the morning. He has worked in a smelting plant for 20 years, no work-related complaints, does not smoke. And during his normal exam, you notice that he has protein in his urine, osteopenia on his x-rays. And on physical exam, you see yellowing of his teeth and fingernails without any other significant findings. What are you worried about? Yep. Cadmium, right? Boom. Let's see. And then in that situation, what would you check for? To be honest with you, I'd do all of them, right? But I think what they're looking for is the urine beta-2 microglobulin. And usually that's the first kind of indication for cadmium exposure. Yeah, it's a board question. Exactly. It's like a buzzword, right? Yeah. Yeah. And then this is also going back to the cadmium question, but which one of the following is true? Which one of the following is true? History of tobacco may affect the levels of cadmium found in the bloodstream. That's obviously yes, right? That's why we want patients to stop smoking if they can. Acute exposures may occur among welders who have unsuspectingly welded on cadmium. Yes. And then the last one is that cadmium is contained in some industrial paints and represent a hazard. So the answer is D to all of the above. No, I completely agree. I always tell my residents, if you miss the first one, you're kind of like down, you're down three questions, you know what I mean? And they don't really like that. But the key here is really analyzing the first of the three. If you know that there's three questions back to back to back, really focus on this question eight, right? Like if you see osteopenia on x-ray, you see the protein in the urine, your radar should go off cadmium. So yeah, yeah, third thing that you described. So it's really a kind of a different way to test. Yeah, I mean, and that's why, so we're going to get into these, but these are rapid buzzwords that I typically find in, you know, repeat board questions or, you know, I use like two or three, like little sources of where I would study for my exams. And I'm like, all right, this always shows up for some odd reason, you know, like we just talked about the beta-2 microglobulin. Like in clinical practice, I'm going to Google it, right? I'm going to find out what I would do, but in examinations, that's what they're looking for. So when you're doing cadmium surveillance, the thing you have to remember is you have to have, when these guys give their urine test, you have to do it before they go to work, come in at, during work or after work, because it's very easy to get it in front of the urine surveillance, you have to have it on the elevator, urine cadmium test, so it's always kind of like the urine before they go to work, not after. That's a very good insight, you know. We have a lot of that stuff. Yeah. Yeah, yeah. Wasn't a clue yet. Well, I did everything right, but the low voice didn't do anything great. We're gonna have to keep you guys in my contacts, just like that. I would be like, hey, what am I doing wrong here? Yeah. So this is an anemone. It's abdominal pain, jaundice, and aneuria, and hemolysis. If you hear those key buzzwords, this is the, your radar should go off for this. The treatment and the usual kind of core question is exchange transfusion. So this is one of those kind of advanced levels. Also, they present in urine, but doesn't correlate with severity. So just because it's a high level doesn't mean that, you know, there's severe toxicity or not. This is my favorite so far, beryllium. For a year or two, well for a year exactly, I was on the east coast of Florida, and we worked out of, what is it, SpaceX and all those guys were rebuilding these spaceships. A lot of times when you're working with the aerospace industry, you're trying to reuse a lot of their equipment. So there's a lot of exposures that you would think are, you know, kind of well controlled, but we saw a lot of beryllium exposure. The test and the buzzword that they usually like to look for is the lymphocyte proliferation or the transformation test. And so that's unique to this certain kind of exposure. The other thing is, you know, it's linked to lung cancer. So similar to how we talked about the other cancer-causing heavy metals, this is huge for that. And, go ahead, sorry. Okay. And even in the Department of Defense, a lot of parts have oil in them, so when it's manufactured, it's exported, and when it's refurbished, that's what SpaceX is doing now. You know, there's a lot of fumes when you bring these ships back, or you bring these shuttles back, and you got to fix them, clean them up, and reuse it, you know. There was a debate when I was out there whether or not they should, you know, not reuse some of these parts. And you think about it, they spend millions and millions of dollars on building these spaceships, and then they're like, okay, we're going to just throw it out. But the exposure risk for the workers is huge. So in order to properly protect your employees, you got to make sure that you take the steps. And I guess OSHA has a standard now, too, so you got to keep those in mind. Manganese, sorry. This is something that's caused idiopathic Parkinsonian. So this is a, you know, similar buzzword notorious for that. And it's a severe acute pneumonitis, and hepatic and renal toxicity. So those are key things to remember for that. Tellurium and selenium, these are also causing a garlic odor and taste. Once again, I don't know how close you guys get to your patients, but I try not to. But this is something that can also lead to this blue-black skin discoloration. And once again, it can also cause rose eyes, which is conjunctivitis, pretty severe conjunctivitis of the eyes. So if you see these patients, I have not run across any other test questions associated with this, but usually it's the blue-black discoloration, garlic odor, and the rose eyes, if you will. All right. I do not know if this picture is true. But it's, I Googled it. I spent like a lot of time trying to figure out if I could find a green tongue. I think this is probably on one of your talks or something. I forget somewhere, but I could not find it. I don't think this is real, but what's that? I'm not gonna lie. But this is, you know, the greenish discoloration of the tongue. I don't know. I've never seen it in practice, but it's a buzzword for this exposure. He looks too young. This has got to be fake. I think I'm going to start taking a picture of my tongue in green and see how long that takes. Chromium causes something called chrome holes in the nose. This is something in the tanning industry, electroplating, and wood preservatives that we were talking about. This can also lead to lung cancer. So it's something to kind of make sure that if you see it, kind of work up your patience pretty fast. And then uremia is usually the cause of death. Okay, good, good. I'm going to send you my PowerPoint. You just change them up however you feel. So phosphorus, also garlic odor again, and this is something interesting. It's the bone necrosis of the jaw. We've seen this not a bunch of times, but mostly on board examination. The flossy jaws is what they look for. And then I can't believe this is real. I think I remember this watching this as a kid at one point, but silver exposure can lead to this bluish discoloration of the face. Actually everywhere, and it's irreversible. I remember reading about this guy, and he literally is blue like this all the time. So that's something interesting. Once again, I really thought these pictures were fake, so I kept trying to find it, but this was, I think it was on a Mori episode or something. Yeah, he's legit. I actually saw the video of him at one point. Yeah, I'm not sure. I'll be honest with you. I didn't dive into it. I just was verifying that he was really blue. Yeah. Yeah, I should. You're right. The other thing I find weird is that there's like a blue background, a blue shirt. Like he could have picked any other color, you know. It's really impressive. Yeah. So chronic arsenic ingestion. We're almost done, guys. May result in which of the following? Right, right. May result in chronic. You're right. I think what they were looking for in this question, I agree with you, but they were also looking to see if it caused cancer of the skin, lungs, and bladder as well. So Borreliosis, this is just a random fact. I didn't really ask you about it, but this is, it can develop even after a single acute exposure. So it's something to keep in mind even after, just to know that what your companies are doing in their facilities, that even after a single exposure, you can get this. And this is that buzzword of the lymphocyte proliferation test we talked about. And the key in here is that it just confirmed sensitization. It doesn't really tell you anything other than that. And then almost the last one, but workers who should be removed from the workplace, lead exposure. And there's, this is controversial, of course, but it's in 2010, the CDC was saying that it should be any prenatal blood greater than 10. I'm not sure if this has changed in the recent months, but like we were saying that the lead levels have been going up and down, but any female above 10, you should get them out of the workplace. What we do is we basically highly recommend removal of that between the employee and their physician. Employee and their physician, did you say? Yeah. Okay. The company cannot do the latter. Right. But this is usually, it's usually the, you can make, just like how you make reasonable accommodations or such, right? No, no, no. You're right. If they maintain their security and their salary. Correct. That's what a lot of companies do. Don't think a lot of that is required of them. Right. That's what I thought. Yes, yes. Correct. You can't remove them from the company. Correct. Yes, yes. I was just saying, remove it from the workplace exposure, not the company itself, but you're right. You're correct. Yeah, of course. Okay. Thank you.

Dr. Patel

pain management

occupational hazards

heavy metal exposure

arsenic poisoning

OSHA compliance

spine and joint pain

chelation therapy

workplace safety