Dr. Scott Everson unfortunately could not be here. He had an accident several days ago. Literally, he texted me and said, unfortunately, I won't be able to be there. He had a pretty tough fall. Actually, I understand some other members of our organization have had falls from ladders. So that tells everybody, watch out for climbing ladders and getting on roofs. He does send his regrets. He wishes that he could be here. So in his place, on very short notice, Colonel Patrick Birchfield has agreed to speak and give this presentation. So we are eternally indebted to you, a past president, of course. He received his doctor of osteopathic medicine degree from Kansas City University. He completed a transitional internship at Dwight D. Eisenhower Army Medical Center in 2003. And in 2004, earned a master's of public health degree from the University of Texas Medical Branch at Galveston. Colonel Birchfield completed the aerospace medicine residency at the Naval Operational Medicine Institute in 2006. And in that same year, became board certified in aerospace medicine from the American Osteopathic Board of Occupational and Preventive Medicine. 2014, Dr. Birchfield became a fellow in the American Osteopathic College of Occupational and Preventive Medicine and served as aerospace division chair, treasurer, president-elect, program chair, president, and past president of AOCOPM. 2018, he was elected a fellow. And he serves on the awards committee and title award committee of that organization as the brand new president-elect. Dan, I think you had something to do with this, for the American Society of Aerospace Medicine Specialists. So let's welcome Patrick. Thank you so much for participating. Well, good morning. Thank you for attending the first lecture at 8 o'clock morning of the AOCOPM mid-year conference that we all love so much. What we love so much about it is the collegiality. And I love seeing each of your faces here time and time again. True friend over a decade. And if you're unfortunate enough to not be able to be here, please consider attending it in person in the future. You just can't replace this kind of collegiality. So what Chris did say was that I am not Scott Everson. Interestingly enough, I did volunteer on short notice to brief his slides, some of which talk about safety. So let that sink in for a moment. Sometimes we don't practice what we preach. I'll be talking his slides on current insights and updates in military occupational medicine. Some people do anything to help their VA's. Right. Listen, there's an easy way to get VA disability, and then there's this way. I don't recommend it. You got a clicker? Do I have a pointer? So how do I apply to figure aid to camp? Aid to camp, so I have to be a lieutenant and not have to train. Oh, I got you. Yeah, it may be a little shorter than anticipated because any of the details are pointing this out. That's right. Witnesses get these guys that look pretty fit, so like maybe generals themselves at some point in their career. You see that knock me out. And you got me. All right, so like Scott, I have no employment or financial influences. If you want to pay me money to have influence on me, we'll talk later. But right now, I don't have any of those. I am employed by the government, the US Army, not the Air Force, so the second bullet remains. And then same thing with the third bullet. I don't have any reason to talk about anything that I'm not getting paid for. OK, and the clicker works. Excellent. So some of the goals of our lecture here today, and I got to tell you, you're going to see me being a little bit uncomfortable for the benefit of our online audience. I'm going to try to stay in this bubble. I'm a walker, so it's going to be painful for me. So I can move around a little bit. I mean, that's actually a little bit scary. How smart am I? The audience is supposed to know what we have here. This is going to be a short lecture. All right, so we're going to review some of the previous and current OEM initiatives. You can read that, understand the hierarchy. As I was reading this and learning to present the information, I learned some stuff about the Air Force Medical Agency, which is fascinating to me. And then the future of OEM and the DoD. Here's some previous and current initiatives. So we have a lot of, based on our clientele and our colleagues, we have a lot of veterans in here. So some of these things may affect you. Any atomic veterans? Did anybody go out to the missile range and watch a, no, no, Murray, no, nobody? All right, so atomic veterans, Operation Tomodachi Registry. Does anybody know what that is offhand? You would, sir. Okay, so that was when the nuclear reactor was compromised and we went and helped clean up. Potential Agent Orange exposure in the Blue Water Navy during the Vietnam War. So now those benefits are extending not from, not only from the Brown Water Navy, but to the Blue Water Navy. Any chemical warfare agents' exposures during testing in the 40s to 75, we would never do that. Chemical warfare agent exposures in OIF, so that's Operation Iraqi Freedom. So some people call that Desert Storm II, that's incorrect. It's actually OIF. That's Desert Storm I, right? So 90 to 91 Gulf War, any exposures that were there. Burn pit emissions that anybody who went overseas got to experience, it's lovely. Potential exposures at K2 Air Base in Uzbekistan. That was a Uzbek Air Force Base that we occupied there for a couple of years. The Camp Lejeune, if you've turned on a radio or SiriusXM or any TV in the past two years, you've heard about the Camp Lejeune water contamination. And then the PFAS groundwater contamination near military bases all over. And then the Red Hill incident in Hawaii, right? That's a fuel leak into potential drinking water. So these are the things that the DoD occupational medicine enterprise as a whole is looking into currently. And you can see there's a lot of stuff on their plate. So just a couple of things on some of the current initiatives. I found this one to be interesting. This is the atomic veterans piece. This is where the VA says, hey, we have these names of people we think might be exposed. Those are given to DTRA, the Defense Threat Reduction Agency. DTRA confirms whether or not that veteran was present and then gives a dose estimate of what they think they might have been exposed to. And then that allows the VA to estimate and determine the eligibility of any compensation or disability that the veteran might be entitled to. And so they actually have an ionizing radiation registry of 18,000 veterans. I didn't realize it was quite that big. Another recent issue is this 1966 plane crash in Palomares, Spain. So there was a B-2, I believe it was a B-2. No, it was a B-52. You're right. During a mid-air refuel, they got a little bit too close and up on a KC-135. Everybody in the KC-135 died. Four of the six, four of the seven, I think survived in the B-52. But they were carrying live nuclear bombs. So the bombs fell, three of which went in the water, one of which went on land, opposite. Three of which went on land, one of which went into the water. They recovered them all eventually. The one in the water took several months. But in that time, it took a lot of people, about 1,600 service members to help with that cleanup. And so now they're decided, hey, maybe we ought to assess these folks for risk for any radiation doses they may have received. The non-nuclear explosives and a couple of the bombs that hit land exploded, right? So there was some contamination field that blew up. So they're looking at that. Veterans were filed a class action suit in 2019. And then there's a Senate bill about the VA compensation for those folks introduced in 2021. The Blue Water Navy piece in 2019, Congress passed a law that says, hey, you need to extend these benefits to folks that were in Blue Water Navy, anywhere within that 12-mile administration zone demarcation line. They estimate, now the VA, this is a burden, right? To this bureaucratic institution. Estimating roughly half a million veterans may be eligible for compensation during that time. And it's interesting the way they did this. So we have to admire the Herculean effort that went into this, because you can see some of the statistics there where they digitized all the ship records, 29 million images to the ship's logs to find out where folks were, who was on what ship, where the ship was, all that kind of stuff, to adjudicate some of these claims. They have 58,000 claims and 72% of which have been granted. So interesting, retroactive epidemiological study using modern techniques on a historic problem. The K2 Air Base in Uzbekistan similarly, in 2020, VA told Congress, hey, we're gonna do this epidemiological study of veterans who were at K2. I'm not gonna say it again. I'm gonna say EPI. I'm gonna say EPI, yeah. So with the help of the Defense Manpower Data Center, the Armed Forces Health Surveillance Division and the U.S. Army Public Health Command, they worked to identify all the service members that were there during that time, about 15,000 of which, and then they're gonna compare that to a comparison group who didn't deploy to K2. That sounds strangely like preventive medicine, public health, the kind of things that we learned during residency. Actually apply to real life situations. And then they're gonna use the DOD medical records to do a retrospective study on the morbidity and mortality. Why are they gonna do that? Because for one reason, in 2021, the Congress passed a law that says you're gonna do that. That always helps, but usually with laws come appropriations and funding, right? So that's probably why that worked into the NDAA. The DOD did perform their own mortality study using the National Death Index and also contracted with Johns Hopkins to perform a study using the VA and medical records. Okay, so that is sort of a brief and quick review of some of the ongoing and current DOD occupational emergency, not emergency medicine, environmental medicine initiatives. Now we're gonna move on to safety and occupational health. I like pictures, I'm a visual guy. To me, the perfect picture here would be Dr. Everson and a ladder maybe. But one of the first things he likes to talk about here in this slide is the structure, where we are and how we got there. You can see this is, you probably can't see because you're all squinting, I can tell. But what you have is the Undersecretary of Defense for Professional and Readiness at the top under the big block. And then you have each of the Undersecretary Deputy Undersecretaries for Health Affairs, Readiness, Manpower and Reserve Affairs, Human Resources Activity, and then the Office of Force Resiliency. There are actually all Assistant Secretaries. Assistant and the Assistant Secretaries of Defense, you're exactly right. Underneath the Health Affairs, the Defense Health Agency, trivially but interestingly, the DECA, the Defense Commissary Agency is under Manpower and Reserve Affairs. But under Readiness, you'll see Safety and Occupational Health. What you might notice at this point is that Safety and Occupational Health is separated from Health Affairs, which has all of the healthcare dollars, right? So I think that's the point he was trying to make on this slide. And then how that creates an efficiency and how we can make that better. He does talk about the Defense Secretary and Oversight Council, right? So how do we look at Safety and from an integrated point of view, when you have things in different columns. And this slide right here explains some of that. And you can see the level, right? So the DSOC has the Undersecretary for Personnel and Readiness. And then the level below that is the integration group, which has that Assistant Secretary of Defense for Readiness. Then underneath of them, there's a two-star group, which is a steering group. And they have all of the strategic communications, resourcing management systems, those kinds of things. And then you have the Safety and Occupational Health Committee sort of underneath of them. And that has sort of your very traditional occupational medicine venues in there, such as hearing conservation, industrial hygiene, OcMed clinics, environmental health, ionizing radiation. And then sister organization to the DSOC, you have Joint Safety Council. So that's where you bring in a little bit of flavor from everybody. An example of how these things work through that process. So you can see in the upper right-hand portion of the inset slide. So this is a DSOC type product. And it just goes to show how these things are done, right? So you have the purpose, you have who's on the board, what their policy is, what their frequency is, how they meet. Then you have their strategic objectives in the upper right-hand corner. You have in the lower left-hand corner some previous fiscal year accomplishments. And then you have their planned accomplishments on the lower right-hand corner. So this is sort of one slide baseball card of what one working group in that DSOC would have. This one happens to be for the Transmitted Electromagnetic Field Radiation Protection Working Group, which is sort of a big thing. Another big thing that didn't make this slide, but I happen to know from going to work every day, is the blast overpressure. So I'm sure if we had this same lecture next year, you would see a blast overpressure as a current and ongoing initiative. So here, this is an interesting opportunity for me to talk about all I know about the Air Force, which is actually encapsulated on this slide. What do you mean by that? The good news is- It's slightly more informed. Yes. But not even the youngest service anymore. They're like the old man now. But I found this very fascinating because the Air Force is different, if you didn't know. And this next slide shows how they are. And I'd always wondered about this. So looking at this gave me the opportunity to do a little bit of learning. So if you look at this, in the top, it says Secretary of Defense. And then you have each of the service branches here. So this is Navy, Army, Air Force, and then it's under Secretary of Defense for Personnel Readiness on the far right. You'll see that in the Navy and the Army, a structure with which I am familiar, you have the Surgeon General. And then that Surgeon General is the commander or has command authority over UMed for the Navy or MedCom for the Army. In their command authorities, the Army at least wears two hats. And the Surgeon General, they are the staff officer to the Chief of Staff for the Army. So they are a staff officer. But they also wear what we call in the Army a green tab. They are a commander. They have command authority of all the medical treatment facilities. So the MedCom own the MTS. Similarly in the Navy, whereas in the Air Force, they have this very separate structure. The Air Force Surgeon General only wears that hat of being the staff officer for the CSAV, the Chief of Staff of the Air Force. And then you have each of the MedComs or major have their own command authority. And then they, through the garrisons or base commander, I think you call them the Air Force, they have command authority there. You can tell the slide's old because under Defense and Personnel Readiness has their Assistant Secretary of Defense for Health Affairs, which owns DHA, which owns the Capital Region Medical Directorate, which then owns the Capital Region Military Treatment Facilities. Now since the DHA takeover, I mean transition, my mentor is the DHA director. I can say that with love, ma'am. So now DHA owns all the MTS. They own, they have Authority Direction Control by Congress. Those are the words Congress uses, Authority Direction and Control, and they have the checkbook as well. So they own all the military treatment facilities. Where does that leave the Air Force Surgeon General? Still policymaker, but as we have moved to operational medicine, it can take out all the military treatment facilities, we now have, what do the services own? The services own operational medicine, and they still have the requirement to train, man, and equip the force, right? So, you have to train, man, and equip the folks that are going to man the hospitals, and then also, perhaps more importantly, the ships, the medical brigades, the medical wings, and whatever the Air Force has, right? So, Air Force, seeing that, has decided to change their structure, interestingly, to a more traditional structure, as seen, and this Air Force Surgeon General here says, as the DHA and the military health services have evolved over the past six years, it has become apparent that the Air Force Medical Service needed to restructure to ensure we could better advocate for our equities and words, words, words, right? In other words, they saw the requirement to move to a more Army and Navy-centric force structure model. So, I found that interesting because I never quite understood how the Air Force did what they did. Each of their MACOMs has what's called a Surgeon General. It blows my mind when I go to joint conferences, they say, oh, you're the Army Surgeon General. In the Army, we only have one Surgeon General, and that's got three stars. And so, I was actually taken aback, affronted. I thought someone was making fun of me. And then I realized, no, that's just the title that they use for that 06 representative to a command. Basically, what the problem is is that the same way that we call the command, you know, the division surgeon, for example, in the Air Force, the Air Division Surgeon, or something slash SG. So, you're right. We use the term in the Army, surgeon, to mean the physician who's advising that command. And just yesterday, I think, I had explained I'm not a surgeon. I am the command's physician. So, it's not that big of a leap to say Surgeon General, I guess, if you're going to throw words on something. It is now, even six-week-flight surgeons. So, the Air Force, in their restructuring, came up with this thing called AFMED, which is very interesting, right? So, that's going to be the equivalent of BUMED or MEDCOM for the Army. They have one of those slides that you're required to have with the waypoints on each one. They did use a pointy-nosed aircraft and a satellite at the end. So, that's very Air Force-centric, and I love it. But what you can see, if you had supervision, is that their IOC was going to be in 1 October 23 and FOC in October 24. Over here, this is an article that shows that they have. They reached IOC in November of 23. So, they're well on their way to creating this structure that more mirrors the other services. Now, some tidbits on the future of DOD safety and occupational health. Again, very Air Force-centric, because an Air Force officer presented it. But keep in mind, as the DHA has taken over the military treatment facilities, the services now have operational medicine, right? So, by law in the NDAA, undersea and hyperbaric medicine, aerospace medicine are retained by the service. So, this, to me, fighting from the fly line, what are the operational medical requirements that the service retains? And you can see, well, again, if you had better vision, you can see there's medical clearance, profile determination, things like that. But when I click the thing, there's a little circle here that says occupational hazard mitigation. So, occupational and environmental medicine is worked into the service's responsibility for operation. And that's, it's new, it's good, it does create some challenges. DOD initiatives, safety studies and GAO engagements. Here's some funded studies. So, for those of us who are aerospace, a lot of this stuff looks like what we do every day, right? Mishap prevention, mishap classification, and then improvements and efficiencies in the private motor vehicle safety program. How they're going to do, and some of their previous engagements, aviation mishaps, service member fatigue, additional actions for tactical vehicle training accidents. We actually kill a lot of soldiers and Marines in tactical vehicle accidents because of the fatigue, the sleepiness, day and night cycles, all the things that we're familiar with. National Guard helicopter accidents. I can only imagine that specifically refers to the Tennessee National Guard Black Hawk that crashed there in Huntsville, where I live. And I got to see a safety debrief on that. It was all the things, all of the aeromedical factors, all the things that we try to prevent were present. I'm sad to say. And then the Ospreys, right now, I don't think I would get on an Osprey. They're back up, I think. Osprey's been a problem, I mean, from the beginning. From the beginning. Here are some health issuances updates. So, this is just, I'm not going to belabor this because it's a lot worse. I've been talking already for at least 10 minutes. So, but it is an update. These slides are available and you can see the kind of updates that are available. This is a safety and occupational health program globally for the DOD. That's going to be expected publication in 2025. Occupational and environmental health. Mishap notification investigation reporting and record keeping. These are at the DOTI level, right? The Department of Defense instruction. DOD manuals for occupational medical exams. Directed type memo saying we will do this for safety and occupational health management. Distinctive directed memo, occupational exposure limits for trichloroethylene and for lead. Apparently, that's a big deal because they're revealed now. But to me, what this means, the so what of this slide, is that there are long range highly educated people looking at the problem sets projected into the future. Because with these come resources, right? To resource and give actionable orders for occupational and environmental medicine. Here's a good example. So, that standardized impact for the exposure limits for lead. This one is, this is an example of the baseball card for working that problem. It's grayed out here because down here it says internal delivery. It don't distribute. So, you know, this is just an example. So, you can see their workflow and how they get at a problem set. Here's another OEM improvements slide. I certainly will not talk about adjacents and dot mil PF. But the bottom line is from the National Security Strategy and the DOD strategic guidance. We understand what our military mission sets are. What we have to do. Who our main adversaries are. How we want to get into stuff. Then we create these joint concepts and continuous operations forecasts. And they help us figure out how we're going to operate in the future environment. So, the future environment is MDO, right? Multi-domain operations. Contested entry, expeditionary entry from the homeland. From the port of debarkation, right? So, everything is on the table. That's the environment we're talking about. Then we create these requirements for test conditions and standards. And what do we not have to be able to operate in that environment? What are the capability gaps? Then what kind of solutions can we come up with? Those solutions go into the requirements calculator. And that calculator spits out ways to enact solutions through the domino PF domain. So, that's what kind of doctrine do we need? What organizations? What kind of training? Here you have a leadership, education, personnel, facilities, and policy. So, if you can get occupational environmental medicine into this. Because built into this is, again, funding and resourcing. Then you have occupational environmental medicine. Not as an afterthought, as it sometimes is. But as baked in, as they say, to the process, the operation process. Improvements in the capabilities-based assessments. Again, determine the capability requirements for occupational medicine. Include the primary responsibility. So, pin the rose on someone, as they say. And improve our ability to conduct operational environmental medicine by safely feeding the worker, right? This is starting to smell like oceans now, right? It started with oceans. Because the military is bound by ocean regulation. So, now we're working it into our doctrine. So, that worker can safely perform their assigned duties. They're not adversely impacting their health. And they're not exposed adversely to hazardous exposures. They came up with these gaps. These are the gaps. Some of these are not surprising. Some of them I would like to learn a little bit more about. So, leadership lacks an understanding. How do you sell health center talent when you don't have health, right? It's the preventive medicine problem. Well, how do you say how many workers didn't get injured, right? So, same thing. Leadership doesn't understand what we do and how we save time, money, and manpower. They lack a comprehensive information system, which they're working on. Not compliant with several federal regulations, including CLABSI, CFR, which has to do with Civilian Workers, Americans with Disabilities Act, and GINA. That scares me. I'd like to know a little bit about how we're not compliant with that. Inconsistently conducted across opponents. Insufficient quality of adequately trained OEM specialists. That's us. And then, not supported by a military health systems resourcing model, because that resourcing model is fixing people that are broken. That's how we fix people that are sick. We don't resource keeping them from being sick. That's just a traditional model that we face in the United States. Here's some capabilities-based milestones. Basically, the outcomes here are working into the JSAIDs and the JROC, right? This four-star level resourcing conferences that determine how the services run and resource. So, if we can work our way into that, occupational environmental medicine will be better than it ever has been. And here is a picture of the strategic plan for 2023. The mission, vision, and goals. The goals relate to what we just talked about in the staffs. Promote and instill the culture. Information in this office. So, an information system. Reduce risks. Reduce programs. Resource the programs, and then advocate for technologies and solutions. So, again, ways to get at resourcing occupational environmental medicine into the operation. A couple of the objectives. And then the individual longitudinal exposure record. So, this is pretty interesting right here, right? So, the idea is we have all of these exposures that one may or may not encounter during the breadth and length of their military career. So, how do you know? How do you know what your field of exposure is or dust and sand? And how that relates to morbidity and mortality in life, right? So, how do we resource compensation or medical care through the VA? Do we just, we right now, we do a lot of presumptive, right? We just presume that those things affect you because you might have been exposed to them. Or you claimed you were exposed to them because you might have secondary intent, right? Vaccines, I don't know why that's the sort of exposure. Depleted uranium, you know, all of these. With the exception of Agent Orange and live nerve agent, I'd say you've all been exposed to some degree to these things. So, this ILR tracks what the exposure is, where it is, the quantity, and then can work in with the manpower, yes, work in with the, I don't have it super convenient for me. But basically, they track where you were as a service member. And that way, they know what your exposures are and then gives you a better idea, the VA a better idea of what you might have been exposed to and how it treated. So, to improve the medical care study, right? So, now we can study these cohorts if we know who they are. Detect emergency latent health conditions. Everybody remembers the desert storm syndrome? Not sure we ever figured that out. But there was something going on. This would help that. And then assist with the veteran feasibility of that patient's benefits determination. Those are the benefits. 6.5 million individual unique exposures. Eliminate some beneficiary burden of proof. Previously documented harmful exposures. So, yes, sir. Who's responsible for keeping the ILE on front? That is, I'm going to talk out of my mind what I think is the right answer. But those agencies that I mentioned earlier, so the armed forces have been so the armed forces, health surveillance service, health surveillance, and the Army Public Health Center. It's going to be those higher up levels that those are the people who, those are the organizations who send out people to do the environmental surveys. And then they would come in and put the documentation that they found into this. Because records like that are the point of contention, particularly in Prevent, because that's the source of data one depends on. And it's many times, particularly in Orange, when there were whole groups of individuals who were not counted, so to speak. Like the Blue Water Navy? That's the right verb. Like the Blue Water Navy. Yep. And you've mentioned that in one of your old bosses, I mean, when you were an agent in Michigan, that was a real concern. So we went out to try to find out because the link between location and exposure and amount of exposure became the key elements for the cohort in case control studies that were done versus liability. We were interested more in the health perspective than the reimbursement. The notion is, is that those become the records upon which we rely. And there is no option for us. At least that was the plan. I was involved in a bunch of different areas, so I can't. But I know that that was a point of discussion. A couple of comments on that. A couple of comments. Number one, the veteran, at least currently, gets to opt in and say, yes, I was exposed. So that's one additional data point that goes in. And then the other thing is, it's a step forward. So while not complete, it is the next baby step forward to creating a database that becomes authoritative. You're always going to miss somebody. So there's got to be a way to kind of scoop up. But you'll have a large amount of people that are already in the database and won't have to make that. Thank you. My question is, when I was enlisted, I didn't get to see this for a while. And then as a flight surgeon, there was an awful lot of people who were unwilling to raise their hands until the very end. We were in a pandemic. Yeah, and a lot of exposure, myself included. For example, I was diagnosed with static myeloma and adenoma. And I was in flight status. The pulmonologist deliberately took that out of my record. And this is later. And so midway through the VA, I'm just like, there's no record. There's not a letter that I need. And so there are a lot of people who are part charters who can't, well, can't get that because stuff was either eliminated or they waited until the end and said, yes, I was exposed. They said, well, approve it. So let me give you a TTP on that, right? Tech, technique, tips, procedures. I can barely bend my left knee right now. I need an albuterol inhaler sometimes that I found on the ground. And various other lies. I'm 1.8 hours away from my natural flight surgeon leaves. After which, miraculously, all of these things will start to become documented.

aerospace medicine

military occupational health

Agent Orange

veterans' health

DOD initiatives

Individual Longitudinal Exposure Record

Colonel Patrick Birchfield