A day that will live in infamy!! MY VA CLAIM WAS APPROVED!!
Eric, my DAV rep, called me at 7:35am and told me that I was approved for 100% Permanent and Total with Aid and Attendance. I will know more when I get my official letter. But bottom line is...
MY VA CLAIM WAS APPROVED!!
Tuesday, January 26, 2010
Tweaks
I have been back in for 3 tweaks so far. My next tweak is scheduled for February 4, 2010.
I have had some gait issues as well as some falls since my last tweak. So we will address these issues with the neurologist.
I have had some gait issues as well as some falls since my last tweak. So we will address these issues with the neurologist.
Turning Me On
That's right, they turned me on on 18 September 2009. Boy, what a difference it makes!!! They did a lot of testing, and after 1-1/2 hours later, I walked out of there feeling great!!!
The feeling great just lasted for 4 days. I go back in in 1-1/2 weeks for another tweak.
The feeling great just lasted for 4 days. I go back in in 1-1/2 weeks for another tweak.
Surgery
My doctor's think that I am an excellent candidate for DBS (Deep Brain Stimulation). So, on August 15, 2009, I go under the knife. After a long 10-1/2 hours in the operating room, I was done. What was really weird was that I was awake for part of the surgery so that they could test the location of the electrodes. They would turn on the juice and sometimes something good happens, and other times it wasn't so good. This was a signal for them to move the electrodes.
But finally, all was done and I was wheeled out and placed in a room for 4 days while I was recovering. It was good because my mom and sister came out here and between them and Jerrilynn, someone was with me the whole time. I don't remember much of that time.
A week later, I went back in so that they could insert the controller just below my right collar bone and connect the wires.
But finally, all was done and I was wheeled out and placed in a room for 4 days while I was recovering. It was good because my mom and sister came out here and between them and Jerrilynn, someone was with me the whole time. I don't remember much of that time.
A week later, I went back in so that they could insert the controller just below my right collar bone and connect the wires.
Second Claim
So now what to do? File another claim? You betcha'. On July 15, 2009, we filed another claim instead of appealing the previous decision. We asked for an increase of the 30% as well as a lot of secondary conditions. Now the waiting game begins again.
VA Award
Well, after 14 months of waiting, the VA approved me for disability and awarded me 30% disability. Only now, the VA is keeping the $450 they would be paying me to pay back the money I received back in 1992 when I voluntarily separated from the Air Force.
Friday, July 10, 2009
My Full IMO
INDEPENDENT MEDICAL OPINION
JUNE 15, 2008
To: VA RSO
RE: MICKEY FLOYD DORTCH
INTRODUCTION:
I reviewed this patient's medical record (military and civilian), along with his impressive self generated, geographically detailed, toxicology report and pertaining lay statements. Please refer to enclosed document VA CLAIM SUPPORT INFORMATION FOR MICKEY DORTCH.
His rare variant of early onset aggressive Parkinson's disease, and its related neuropsychiatric sequelae of, lewy body dementia and toxin induced depression, all signify a toxic exposure syndrome. His toxin induced neurodegenerative diseases (parkinsonism, clinical depression and Lewy Body dementia) is well supported by his past active duty locations, early presentation of neurologic symptoms and chronic low exposure toxicity symptomatology. This will all be delineated and presented in detail, with full medical literature review support.
In addition, extensive medical literature from respected peer reviewed medical journals, textbooks of great reverence in various specialties, and Mr. Dortch's own well done research, further lend merit to the exact nexus of his neurodegenerative diseases (PD, LBD and Depression). This nexus being, that more like than not, his pathologic, psychiatric and functional capacity impairment are service connected.
Exposures to known neurotoxic agents are at the crux of his current inability to ever work or meet most of his ADLs (activities of daily living) independently.
An independent medical opinion concerning his Parkinson's disease, Clinical Depression, Lewy Body dementia, total unemployability, and their service connection relationship was performed. His overall functional impairment renders him, without any doubt, 100% disabled. This is due to the facts, that his chronic and progressive movement disorder (Parkinson's disease) and Lewy Body Dementia and Depression (memory and mood illnesses) has and will continue to cause decline, to his physical, mental, and emotional health. All spheres of his humanity will continue to suffer (physical, mental and emotional).
Mr. Dortch is a 45-year-old former Air Force officer who first entered active duty on April 9, 1985 and was discharged September 8, 1992.
In order to make my evaluation I have carefully reviewed the following information:
1. Service medical records
2. Post service medical records
3. Recent rating decisions
4. Toxicology, occupational safety and organic chemistry texts
5. DD2l4
6. Medical literature review
7. CFR Title 38 VA document
8. Medication list
9. MSDS sheets
10. Lay statements
COMPETENCY:
The following opinions are all to a high degree of medical certainty according to my experience working within the general principles of occupational, neurologic, and evaluative medicine.
I am a veteran of the US Navy and served 5 years as an active duty medical officer (physician). I have worked within Naval Medical Centers Internal Medicine and Substance Abuse Rehabilitation Departments. I am also the former Medical Officer of the USS Theodore Roosevelt (CVN 71). I am an OIF veteran myself.
After the Navy, I worked for QTC Medical Services as a C&P examiner. I was paid a flat fee for: 1) examining claimants in person and rendering an evaluation report (IME); 2) and examining C files sent to me from the VA regional service offices and private practitioners. My task was then to, prepare an opinion regarding disputed claims (IMO). The VA paid a flat fee for both the (IME) and (IMO) regardless of what decision(s) I rendered.
I also continue to work in the field of addiction medicine as a MRO evaluating drug testing and have enhanced and extensive experience in the pharmacology, toxicology and kinetics of prescribed medications and illicit drugs. I was the past medical director of the Department Of Defense's largest dual diagnosis inpatient chemical dependency facility. The facility had 80 inpatient beds for all members of the Department of Defense.
My post QTC occupation is that of an academic training neurologist, for a large university based teaching program.
I am highly competent to make this medical opinion, because I am a licensed physician with specialized training and experience in the areas of interest. I performed several hundred veteran administration independent medical exams and independent medical opinions as a employee of QTC Medical Services. QTC Medical Services is a contract organization employed by the veterans administration nationwide. The VA pays QTC contracted physician's to conduct compensation and pension exams and opinions. As an employee of QTC, I have extensive knowledge reviewing medical records and rendering opinions within the VA Rating System. I reviewed the medical records and all lay statements.
I referenced current applicable publications and explained how they apply to the patient's medical and impairment conditions. I have examined the patient, by way of reviewing his medical reports, and returned data sheets specific to C & P worksheets the VA requires. I reviewed and referenced other physician's professional medical opinions (to include radiographic, laboratory, electrophysiological and ophthalmic test results).
I do not have any personal interest in this case, as I charge a flat fee for service, which is paid prior to the writing of the report. This IMO has been performed under the same manner I was paid to perform IMOs at QTC. QTC get millions of dollars from the VA to do the same IMO as I have done here.
BACKGROUND:
Claimant entered service fit for duty (1985).
Claimant honorably discharged from active duty (1992).
Claimant is presently 0% overall rated for, his clearly service connected, toxin-induced neurologic diseases (PD and Lewy Body dementia), and associated depression.
Claimant is currently unemployed and unable to obtain meaningful employment, due to the cumulative effects of his physical, cognitive and emotional impairments.
Claimant has functional impairment, from his conditions, that have steadily increased.
Claimant is currently on long-term disability and has not worked since August 2005.
Claimant's post service occupation was that of a government contracted computer programmer. This was curtailed due to his movement and memory disorders.
Claimant first began experiencing gross symptoms and impairments in 2000, which have steadily declined.
Claimant has ample in service records, that show early manifestation of parkinsonism and chronic low-level toxicity (poisoning) syndrome.
Please note that this opinion is academic in nature and as such, it is not meant to reflect negatively on any other professional.
Mr. Dortch has constructed a very detailed biographical, occupational, geographical, and toxicological report; regarding his pre-service, in-service, and post-service health care findings.
I highly advise that the VA raters read his report (VA Claim Support Information) from cover to cover. It has been included in the cover of the binder, in its own presentation folder and accompanied by the data CD, with all references cited for your detailed review.
Below are just some exemplified quotes, but they do not capture his full occupational, health and environmental histories.
Sections quoted from his diligently derived research and presentation are included below.
Background
"My pre-military and post-military environments were ones relatively devoid of toxic exposures, with neither significant agricultural pesticide use nor industrial or traffic pollution."
"I was born in Little Rock, Arkansas where I lived for 19 years. I then moved to Bismarck, Arkansas where I lived until graduating from college in 1984 with a Bachelor of Science in computer science. I then moved to the Arizona with my mother and sister, on April 1985, I joined the Air Force."
"Upon leaving the Air Force in September 1992, I worked as a government contractor at Goodfellow Air Force Base, Texas until August 1997. I then moved to North Liberty, Iowa where I was employed as a software developer until going on a long-term disability in August 2005."
"Around Christmas time of 2000, I first noticed my left pinky shaking mildly for a few seconds at a time. On September 26, 2001, I was diagnosed with Parkinson's disease. In July 2005, I was further diagnosed with Lewy body dementia."
Kelly Air Force Base Background
"Kelly Air Force Base was established in 1916, it is the first military air base in Texas. It was used as a military depot and a major training site. In the World War II, an increased emphasis was placed on the base depot level maintenance activities. Kelly Air Force Base manages more than 75% of the aircraft and all delivery engines for the entire US Air Force. It also utilizes 1000 galloons of fuels oil: solvents, and other petroleum products. Past waste management practices at Kelly Air Force Base resulted in several releases of industrial chemical contaminates. The most common contaminates were chlorinated solvents (i.e. PCE, TCE, 1,2-DCE, and vinyl chloride."
"The possible routes of human exposure to these contaminated of concern are as follows: drinking the shallow groundwater, inhalation of chemicals released to soil gas, or ingestion of chemicals taken up by plants."
"PCE and TCE are common solvents that were used at Kelly to degrease the engine parts. Over the years, the chemicals entered the shallow groundwater as a result of leaks, spills, or disposal practices that were proved at that time."
"Industrial waste from activities conducted at KAFB are alleged to have contaminated the shallow groundwater and soil in and around KAFB with organic solvents and other toxic compounds. Trichloroethylene (TCE) and Tetrachloroethylene (perchloroethylene; PCE) among several contaminates discovered in the groundwater under the base."
Of note most of the described organic solvents discussed above are metabolized mitochodrially and hepatically via enzyme oxidation and glucoronidation processes that create vinyl chloride as an end product.
A brief example or illustration is as follows (TCE & TCA = trichloroethylene, which when inhaled/ingested/injected-----> mitochondrial dependent enzymatic and hepatic intrinsic processing transpires------> vinyl chloride (final active metabolite and known noxious neurologic damaging and cancer promoting agent) is formed.
"According to the records search conducted in 1982, outdated pesticides in the containers were disposed during the 1950s and 1960s at various landfill sites, located and what is currently the golf course, along Leon Creek."
"Contaminated groundwater plumes have been present at the Gateway Valley Golf Course location for many years. Holes that are affected include: 3, 4, 5, 6, 11, 12, 13, 14, and 15."
My Kelly Air Force experience
"While stationed at Kelly Air Force Base, I worked at head quarter electronic security command in building 2001 located on Security Hill. Attachment #1 shows the basic layout of Kelly Air Force Base."
PLEASE REFER TO AND READ THE ENTIRE DOCUMENT "VA CLAIM SUPPORT INFORMATION FOR MICKEY F. DORTCH"
The report contain well documented and well researched waste sites detected at Kelly Air Force base, which coincides with his occupational location and recreational use of the golf course located on base property. Within this document, Mr. Dortch has succinctly delineated possible exposure pathways, soil and groundwater data, and chemicals of known concern.
Please refer to page 5 of his VA support information for Mickey F. Dortch document. You will see many organic solvents, heavy metals, and known carcinogens, and neurotoxic substances. They are listed with the soil and groundwater concentrations measured in milligrams/liter. Most notable are the high values within the groundwater, located on Kelly Air Force Bases at the time of his service. For example, diethyl phthalate at a groundwater PRG 28 mg per liter. Phenol had a soil PRG of 51.4 mg per liter and a groundwater PRG of 21 mg per liter.
Carbon disulfide, a well-known neurotoxin at Kelly Air Force Base's soil had a grossly elevated 112 PRG mg per liter and groundwater with an elevated 3.5 PRG mg per liter. Barium had a grossly elevated 20,882 PRG mg per liter in the soil and a mildly elevated 2 PRG mg per liter in the groundwater. Heavy metals known, to cause various neurological, hematological, and cognitive declines, found at Kelly Air Force Base in elevated quantities in both the groundwater and soil: barium, copper, manganese, vanadium, zinc, and cadmium. Of most concern is that of the heavy metal, manganese since magnesium has been well studied, well established and well known to induce early onset parkinsonism among welders. This is secondary to their use of welding rods that release manganese-related fumes.
The organic solvent trichloroethylene, 1,2-dichloroethylene, and benzopyrene, within Kelly Air Force Base's groundwater and soil concentrations, are documented to have been elevated beyond acceptable limits.
Please refer to the numerous highlighted remarks in his report, with the common denominator being trichloroethylene and other potent known noxious organic solvents. These solvents and manganese being present, in higher than normal quantities, within Kelly Air Force base's golf course, landfills and the nearby work place of Mr. Dortch, draws a strong correlation. "The reference table location LF0l7 (D-7) showed the trichloroethylene level of 13,000 mg per liters in the groundwater." Further groundwater findings of concern show manganese at the elevated levels of 6.9 mg per liter in the soil and 13.8 mg per liter detected in the groundwater. This was located at LF0l4 (D-4). Last but not least, please refer within the provided table LF00l (D-9) 4-methyl-1-2-10, which is also known as MIBK in the industrial world. MIBK is a potent organic solvent good for removing grease, paint, and many other hard to clear carbon-based substances. KAFB's 4-methyl-2-pentanone (MIBK) had an elevated soil value 1.7 mg/L and grossly elevated ground water value of 74 mg/L.
Mr. Dortch has even done research regarding the neurological effects and the toxicological profile of chemicals that were known to be present and improperly disposed off and/or monitored at Kelly Air Force Base. The data is arrived from toxicological profiles of chemicals from the Agency for Toxic Substances and Disease Registry (ATSDR).
A quoted example;
Aroclor-1232 (PCB) "the neurological effects of PCB's have been extensively investigated in humans and animals. Dopamine, serotonin, norepinephrine, and the metabolites, as well as acetylcholine activity were assayed in the frontal cortex, nucleus accumbens, caudate nucleus, hippocampus, and substantia nigra. The most consistent results from studies that examined the neurochemical effects of PCB in disease and dopamine concentrations in different areas of the brain. Studies with PCB in rats and monkeys observe decreases in defaming in the caudate striatum, substantia nigra, putamen, hypothalamus, and the olfactory tract."
Of note, the above-described symptoms of PCB are nearly identical of those found in idiopathic and toxin-induced Parkinson's disease.
Trichloroethylene (TCE) "follow-up of an acute exposure case indicated permanent nerve damage resulting from exposure to an unknown level of trichloroethylene, with residual deficits in neurological function noted 12 to 18 years after the exposure (Feldman et al 1985). These deficits entailed neuroophthalmological impairment such as asymmetric pupil responses and also neuropsychological impairments such as memory deficits. Intermittent chronic exposure of workers to trichloroethylene has produced neurological effects similar to those found in acute exposure situations. Studies on the neurological effects of acute trichloroethylene inhalation in animals have produced results similar to these events. There are several case studies and acute accidental ingestion of varying amounts of trichloroethylene by humans (Byers et al 1988: Lagakos et al 1986). Some other peoples from this population did show residual damage to the facial and trigeminal nerve measured by decreased blink reflex indicating damage to cranial nerves V and VII.
Manganese (Mn) is well known and ubiquitous among the welding population, to induce parkinsonism, even if there are no family history or other exacerbating or exposure factors to explain their movement disorder. It is uniquely and unusually displayed in early age, versus idiopathic Parkinson's disease.
Mr. Dortch also delineates under the heading of "additional significant reports" an elaborate report on carcinogens by the US Department of Health and Human Services released on January 31, 2005, the following COC were listed to be known to be human carcinogens.
1. Benzene.
2. Vinyl chloride.
The following COC were listed as reasonably anticipated to be human carcinogens:
1. 1-4-dichlorobenzene.
2. Naphthalene.
3. Polychlorinated biphenol (PCB).
4. Tetrachloroethylene (PCE).
5. Trichloroethylene (TCE, TCA).
"A report, assessing a human health risk of trichloroethylene, released by the National Academy of Sciences in 2006, was prompted because government agencies and scientific community have engaged in much debate over the quality of some data and how to assess the information. Several government agencies requested a study by the National Research Council. Data that provide independent guidance and scientific issue to support objectively and scientifically balanced health risk assessment for trichloroethylene.
"This extensive report is included as reference 7." "Taken from that report includes in the reference 7 are following key excerpts" dopamine pathways of the central nervous system are critical for cognitive and executive functions. Studies show effects of trichloroethylene on serotonin neurotransmitter system Dopaminergic consequences likely contribute to motor deficits associated with trichloroethylene."
"The case report observation ...... also described the loss of dopamine neurons in substantia nigra pars compacta (the hallmark of Parkinson's disease) after intraperitoneal injections of trichloroethylene.
"A biological basis for trichloroethylene's potential contribution of Parkinson disease had been suggested by (Rieder et al 2002) to be based on the formation on the potent dopaminergic neurotoxin that could be found endogenously after exposure to trichloroethylene. Of note, trichloroethylene breaks down fairly easily and quickly in the vinyl chloride, a very well known and established human carcinogen. (In the study from the University of Kentucky and published in the annuals of neurology online version December 21, 2007, the full study is included as reference 4).
"Trichloroethylene is a probable risk factor for Parkinson's disease and parkinsonism. Based on the study of workers in an industrial plant and from animal experimental the chemical has been identified as an environmental contaminated by the EPA.
Please refer to Mr. Dortch's composed (VA CLAIM SUPPORT REPORT INFORMATION FOR MICKEY F. DORTCH).
It is also important to state the fact that Mr. Dortch suffered from young-onset Parkinson's disease, which is even more uncommon, and not seen as often as, the idiopathic more common form in those over 50. The fact that most of his pre-military and post-military environments were relatively devoid of any toxic exposures, further support his claim that his neurodegenerative diseases (Parkinson's disease, Lewy Body Dementia, Neurotoxin induced depression) have more likely than not, been directly caused by has presence at Kelly AFB during the early 1990's.
Full-blown parkinsonism usually takes close to 20 years to clearly manifest. In the most unfortunate, then it can progress further to Lewy Body dementia and depression, 5-10 years after the PD is evident.
Mr. Dortch fits the above category based upon review of his Phoenix MEPS, in service, and post service medical records.
The 6 agents documented at Kelly AFB in elevated levels in his vicinity of most concern and focus are the follow;
1. TCE, TCA
2. Mn Manganese
3. CS2 Carbon Disulfide
4. Vinyl Chloride
5, MIBK
6. The collective class of PCBs
The next page details how a young man from Phoenix entered the AF without any MEPS waivers or remarks on his physical. Upon transfer to Kelly AFB he began experiencing increased sick call visits for Upper Respiratory System complaints (URI without any cultured or antibiotic responsive empiric viral, fungal, protist or bacterial pathogens). Also he began suffering, during his time at Kelly many gastrointestinal problems, such as nausea, vomiting, dyspepsia and diarrhea. Mr. Dortch also during the early and mid 1990s while at Kelly AFB, besides his URI, airway irritation and GI symptoms of a constant and unexplained pattern, had episodes of neurologic dysfunction to include vertigo, headaches, cranial nerve palsies and ophthalmoplegia and memory and mood disturbances.
No concrete explanations were ever provided to him during his numerous sick call visits at Kelly. He was never referred to the appropriate specialists, after numerous presentations for the same 3 areas of injury and illness (ENT/Pulm, GI and neurology). This is medical protocol for GPs to defer to specialists, if after 1-2 times the patient returns or fails to improve, in regards to certain organ systems etc. More often than not, he was simply seen by a nonphysician extender (NP or PA) and never saw a GP MD/DO to evaluate his chronic and plaguing symptoms. Symptoms only which he began experiencing or exacerbated when arriving at Kelly AFB.
Phayringitis, asthma, gastritis with nausea, vomiting, nausea and weight loss are all common toxidrome symptoms secondary to organic solvents and/or heavy metals. His nystagmus, vestibular dysfunction and mood/memory decline are further evidence of a toxidrome from heavy metals and organic solvents common to industrial degreasing, painting, cleaning and welding.
As is common in PD, it takes sometimes 6-20 years for enough dopaminergic destruction to take place before overt tremors, bradykinesias and rigidity set in noticeably.
Mr. Dortch entered active duty 1985, free of any GI, ENT, Pulmonary, Neurologic and Psychiatric illness or injury. His JAN 21 1985 MEPS (PHOENIX AZ) essentially granted him a clean bill of health (Dr Stephen Toth, MD). Please see the second tab with included MEPS document.
Once he arrived at Kelly AFB in 1990 he began presenting to sick call for repeated GI (gastritis, nausea, vomiting, diarrhea), ENT (rhinosinusitis, pharyngitis, coryza/ red eye), Pulmonary (reactive airway episodes or chemically triggered asthma) and Neurological (vertigo, headache, lateral gaze nystagmus).
During the span of 2 years 1990-1992 while at Kelly AFB, he was never referred to the appropriate specialists for repeated presentations of symptoms with unknown etiologies. Often seen only by PAs not even physicians let alone gastroenterologists, neurologists, psychiatrists, ENT or pulmonologists.
His VA SUPPORT CLAIM toxological and geographical report data coincides with his GI, ENT, PULMONARY and NEUROLOGIC symptoms.
It is my opinion he was suffering a toxidrome, from a synergy of the listed neurotoxic agents (TCE, TCA, PCE, CD, MN and VC) who have been known to irritate the GI, RESPIRATORY and CNS systems.
I have conducted an exhaustive medical and safety literature search and included it under tab 4. All medical data supporting his claim of early onset, toxin induced parkinsonism, Lewy Body dementia and depression has been included and the most pertinent portions highlighted for your ease of review.
I have also read, researched and analyzed the safety data via MSDS sheets and previous cases and news releases of TCE, MN, VC, CD induced neurologic disease and ENT/GI irritation. These have been included under tab 5 with all the most supportive data highlighted for your review.
Mr. Dortch's healthy entry into service (MEPS 1985 Phoenix AZ), and then a subtle toxidrome manifested at Kelly AFB, via his frequent GI, ENT, RESPIRATORY and NEUROLOGIC ailments (see tab 2 highlighted sick call SF 600s) coincide with his temporal and physical location on an instigation with known neurotoxic, carcinogenic and GI/RESP/EYE/ENT irritating noxious agents.
His VA CLAIM SUPPORT and CD with valid references have been included and explain more than anything else, how he became debilitated at such a young age. His illness has no age consistency nor pre or post military toxic exposures to account for the rare event of early onset parkinsonism.
His Kelly AFB associated sick call visits manifested go, ENT and PULM complaints (toxidrome) and neurologic symptoms. This is where the nexus and clinical manifestation of, what now renders him physically, cognitively and emotionally infirmed and progressively worsening, started.
His chronic toxic exposure (Kelly AFB years) was starting to create the neurodegenrative diseases (PD, LBD) that take 6-20 years to fully express themselves clinically. Every included document, I submitted has been read analyzed and highlighted in support of his claim, to include his medical records and the general medical and scientific literature.
Thus to deny him a service connection based off all the presented evidence is negligent at best. He has no ability to gain or sustain any employment and will most likely decompensate physically, cognitively and emotionally. No cure for PD, LBD or toxin induced depression currently exists.
I OPINE THAT HIS NEUROLOGIC ILLNESS (PD AND LBD) AND DEPRESSION, IS MORE LIKELY THAN NOT, DIRECTLY RELATED TO HIS KELLY AFB SERVICE AND TOXIC EXPOSURES. ALL THE INCLUDED EVIDENCE IF READ, CLEARLY SUPPORTS THIS CLAIM.
Sincerely;
Dennis B. Barson, D.O., CMRO
JUNE 15, 2008
To: VA RSO
RE: MICKEY FLOYD DORTCH
INTRODUCTION:
I reviewed this patient's medical record (military and civilian), along with his impressive self generated, geographically detailed, toxicology report and pertaining lay statements. Please refer to enclosed document VA CLAIM SUPPORT INFORMATION FOR MICKEY DORTCH.
His rare variant of early onset aggressive Parkinson's disease, and its related neuropsychiatric sequelae of, lewy body dementia and toxin induced depression, all signify a toxic exposure syndrome. His toxin induced neurodegenerative diseases (parkinsonism, clinical depression and Lewy Body dementia) is well supported by his past active duty locations, early presentation of neurologic symptoms and chronic low exposure toxicity symptomatology. This will all be delineated and presented in detail, with full medical literature review support.
In addition, extensive medical literature from respected peer reviewed medical journals, textbooks of great reverence in various specialties, and Mr. Dortch's own well done research, further lend merit to the exact nexus of his neurodegenerative diseases (PD, LBD and Depression). This nexus being, that more like than not, his pathologic, psychiatric and functional capacity impairment are service connected.
Exposures to known neurotoxic agents are at the crux of his current inability to ever work or meet most of his ADLs (activities of daily living) independently.
An independent medical opinion concerning his Parkinson's disease, Clinical Depression, Lewy Body dementia, total unemployability, and their service connection relationship was performed. His overall functional impairment renders him, without any doubt, 100% disabled. This is due to the facts, that his chronic and progressive movement disorder (Parkinson's disease) and Lewy Body Dementia and Depression (memory and mood illnesses) has and will continue to cause decline, to his physical, mental, and emotional health. All spheres of his humanity will continue to suffer (physical, mental and emotional).
Mr. Dortch is a 45-year-old former Air Force officer who first entered active duty on April 9, 1985 and was discharged September 8, 1992.
In order to make my evaluation I have carefully reviewed the following information:
1. Service medical records
2. Post service medical records
3. Recent rating decisions
4. Toxicology, occupational safety and organic chemistry texts
5. DD2l4
6. Medical literature review
7. CFR Title 38 VA document
8. Medication list
9. MSDS sheets
10. Lay statements
COMPETENCY:
The following opinions are all to a high degree of medical certainty according to my experience working within the general principles of occupational, neurologic, and evaluative medicine.
I am a veteran of the US Navy and served 5 years as an active duty medical officer (physician). I have worked within Naval Medical Centers Internal Medicine and Substance Abuse Rehabilitation Departments. I am also the former Medical Officer of the USS Theodore Roosevelt (CVN 71). I am an OIF veteran myself.
After the Navy, I worked for QTC Medical Services as a C&P examiner. I was paid a flat fee for: 1) examining claimants in person and rendering an evaluation report (IME); 2) and examining C files sent to me from the VA regional service offices and private practitioners. My task was then to, prepare an opinion regarding disputed claims (IMO). The VA paid a flat fee for both the (IME) and (IMO) regardless of what decision(s) I rendered.
I also continue to work in the field of addiction medicine as a MRO evaluating drug testing and have enhanced and extensive experience in the pharmacology, toxicology and kinetics of prescribed medications and illicit drugs. I was the past medical director of the Department Of Defense's largest dual diagnosis inpatient chemical dependency facility. The facility had 80 inpatient beds for all members of the Department of Defense.
My post QTC occupation is that of an academic training neurologist, for a large university based teaching program.
I am highly competent to make this medical opinion, because I am a licensed physician with specialized training and experience in the areas of interest. I performed several hundred veteran administration independent medical exams and independent medical opinions as a employee of QTC Medical Services. QTC Medical Services is a contract organization employed by the veterans administration nationwide. The VA pays QTC contracted physician's to conduct compensation and pension exams and opinions. As an employee of QTC, I have extensive knowledge reviewing medical records and rendering opinions within the VA Rating System. I reviewed the medical records and all lay statements.
I referenced current applicable publications and explained how they apply to the patient's medical and impairment conditions. I have examined the patient, by way of reviewing his medical reports, and returned data sheets specific to C & P worksheets the VA requires. I reviewed and referenced other physician's professional medical opinions (to include radiographic, laboratory, electrophysiological and ophthalmic test results).
I do not have any personal interest in this case, as I charge a flat fee for service, which is paid prior to the writing of the report. This IMO has been performed under the same manner I was paid to perform IMOs at QTC. QTC get millions of dollars from the VA to do the same IMO as I have done here.
BACKGROUND:
Claimant entered service fit for duty (1985).
Claimant honorably discharged from active duty (1992).
Claimant is presently 0% overall rated for, his clearly service connected, toxin-induced neurologic diseases (PD and Lewy Body dementia), and associated depression.
Claimant is currently unemployed and unable to obtain meaningful employment, due to the cumulative effects of his physical, cognitive and emotional impairments.
Claimant has functional impairment, from his conditions, that have steadily increased.
Claimant is currently on long-term disability and has not worked since August 2005.
Claimant's post service occupation was that of a government contracted computer programmer. This was curtailed due to his movement and memory disorders.
Claimant first began experiencing gross symptoms and impairments in 2000, which have steadily declined.
Claimant has ample in service records, that show early manifestation of parkinsonism and chronic low-level toxicity (poisoning) syndrome.
Please note that this opinion is academic in nature and as such, it is not meant to reflect negatively on any other professional.
Mr. Dortch has constructed a very detailed biographical, occupational, geographical, and toxicological report; regarding his pre-service, in-service, and post-service health care findings.
I highly advise that the VA raters read his report (VA Claim Support Information) from cover to cover. It has been included in the cover of the binder, in its own presentation folder and accompanied by the data CD, with all references cited for your detailed review.
Below are just some exemplified quotes, but they do not capture his full occupational, health and environmental histories.
Sections quoted from his diligently derived research and presentation are included below.
Background
"My pre-military and post-military environments were ones relatively devoid of toxic exposures, with neither significant agricultural pesticide use nor industrial or traffic pollution."
"I was born in Little Rock, Arkansas where I lived for 19 years. I then moved to Bismarck, Arkansas where I lived until graduating from college in 1984 with a Bachelor of Science in computer science. I then moved to the Arizona with my mother and sister, on April 1985, I joined the Air Force."
"Upon leaving the Air Force in September 1992, I worked as a government contractor at Goodfellow Air Force Base, Texas until August 1997. I then moved to North Liberty, Iowa where I was employed as a software developer until going on a long-term disability in August 2005."
"Around Christmas time of 2000, I first noticed my left pinky shaking mildly for a few seconds at a time. On September 26, 2001, I was diagnosed with Parkinson's disease. In July 2005, I was further diagnosed with Lewy body dementia."
Kelly Air Force Base Background
"Kelly Air Force Base was established in 1916, it is the first military air base in Texas. It was used as a military depot and a major training site. In the World War II, an increased emphasis was placed on the base depot level maintenance activities. Kelly Air Force Base manages more than 75% of the aircraft and all delivery engines for the entire US Air Force. It also utilizes 1000 galloons of fuels oil: solvents, and other petroleum products. Past waste management practices at Kelly Air Force Base resulted in several releases of industrial chemical contaminates. The most common contaminates were chlorinated solvents (i.e. PCE, TCE, 1,2-DCE, and vinyl chloride."
"The possible routes of human exposure to these contaminated of concern are as follows: drinking the shallow groundwater, inhalation of chemicals released to soil gas, or ingestion of chemicals taken up by plants."
"PCE and TCE are common solvents that were used at Kelly to degrease the engine parts. Over the years, the chemicals entered the shallow groundwater as a result of leaks, spills, or disposal practices that were proved at that time."
"Industrial waste from activities conducted at KAFB are alleged to have contaminated the shallow groundwater and soil in and around KAFB with organic solvents and other toxic compounds. Trichloroethylene (TCE) and Tetrachloroethylene (perchloroethylene; PCE) among several contaminates discovered in the groundwater under the base."
Of note most of the described organic solvents discussed above are metabolized mitochodrially and hepatically via enzyme oxidation and glucoronidation processes that create vinyl chloride as an end product.
A brief example or illustration is as follows (TCE & TCA = trichloroethylene, which when inhaled/ingested/injected-----> mitochondrial dependent enzymatic and hepatic intrinsic processing transpires------> vinyl chloride (final active metabolite and known noxious neurologic damaging and cancer promoting agent) is formed.
"According to the records search conducted in 1982, outdated pesticides in the containers were disposed during the 1950s and 1960s at various landfill sites, located and what is currently the golf course, along Leon Creek."
"Contaminated groundwater plumes have been present at the Gateway Valley Golf Course location for many years. Holes that are affected include: 3, 4, 5, 6, 11, 12, 13, 14, and 15."
My Kelly Air Force experience
"While stationed at Kelly Air Force Base, I worked at head quarter electronic security command in building 2001 located on Security Hill. Attachment #1 shows the basic layout of Kelly Air Force Base."
PLEASE REFER TO AND READ THE ENTIRE DOCUMENT "VA CLAIM SUPPORT INFORMATION FOR MICKEY F. DORTCH"
The report contain well documented and well researched waste sites detected at Kelly Air Force base, which coincides with his occupational location and recreational use of the golf course located on base property. Within this document, Mr. Dortch has succinctly delineated possible exposure pathways, soil and groundwater data, and chemicals of known concern.
Please refer to page 5 of his VA support information for Mickey F. Dortch document. You will see many organic solvents, heavy metals, and known carcinogens, and neurotoxic substances. They are listed with the soil and groundwater concentrations measured in milligrams/liter. Most notable are the high values within the groundwater, located on Kelly Air Force Bases at the time of his service. For example, diethyl phthalate at a groundwater PRG 28 mg per liter. Phenol had a soil PRG of 51.4 mg per liter and a groundwater PRG of 21 mg per liter.
Carbon disulfide, a well-known neurotoxin at Kelly Air Force Base's soil had a grossly elevated 112 PRG mg per liter and groundwater with an elevated 3.5 PRG mg per liter. Barium had a grossly elevated 20,882 PRG mg per liter in the soil and a mildly elevated 2 PRG mg per liter in the groundwater. Heavy metals known, to cause various neurological, hematological, and cognitive declines, found at Kelly Air Force Base in elevated quantities in both the groundwater and soil: barium, copper, manganese, vanadium, zinc, and cadmium. Of most concern is that of the heavy metal, manganese since magnesium has been well studied, well established and well known to induce early onset parkinsonism among welders. This is secondary to their use of welding rods that release manganese-related fumes.
The organic solvent trichloroethylene, 1,2-dichloroethylene, and benzopyrene, within Kelly Air Force Base's groundwater and soil concentrations, are documented to have been elevated beyond acceptable limits.
Please refer to the numerous highlighted remarks in his report, with the common denominator being trichloroethylene and other potent known noxious organic solvents. These solvents and manganese being present, in higher than normal quantities, within Kelly Air Force base's golf course, landfills and the nearby work place of Mr. Dortch, draws a strong correlation. "The reference table location LF0l7 (D-7) showed the trichloroethylene level of 13,000 mg per liters in the groundwater." Further groundwater findings of concern show manganese at the elevated levels of 6.9 mg per liter in the soil and 13.8 mg per liter detected in the groundwater. This was located at LF0l4 (D-4). Last but not least, please refer within the provided table LF00l (D-9) 4-methyl-1-2-10, which is also known as MIBK in the industrial world. MIBK is a potent organic solvent good for removing grease, paint, and many other hard to clear carbon-based substances. KAFB's 4-methyl-2-pentanone (MIBK) had an elevated soil value 1.7 mg/L and grossly elevated ground water value of 74 mg/L.
Mr. Dortch has even done research regarding the neurological effects and the toxicological profile of chemicals that were known to be present and improperly disposed off and/or monitored at Kelly Air Force Base. The data is arrived from toxicological profiles of chemicals from the Agency for Toxic Substances and Disease Registry (ATSDR).
A quoted example;
Aroclor-1232 (PCB) "the neurological effects of PCB's have been extensively investigated in humans and animals. Dopamine, serotonin, norepinephrine, and the metabolites, as well as acetylcholine activity were assayed in the frontal cortex, nucleus accumbens, caudate nucleus, hippocampus, and substantia nigra. The most consistent results from studies that examined the neurochemical effects of PCB in disease and dopamine concentrations in different areas of the brain. Studies with PCB in rats and monkeys observe decreases in defaming in the caudate striatum, substantia nigra, putamen, hypothalamus, and the olfactory tract."
Of note, the above-described symptoms of PCB are nearly identical of those found in idiopathic and toxin-induced Parkinson's disease.
Trichloroethylene (TCE) "follow-up of an acute exposure case indicated permanent nerve damage resulting from exposure to an unknown level of trichloroethylene, with residual deficits in neurological function noted 12 to 18 years after the exposure (Feldman et al 1985). These deficits entailed neuroophthalmological impairment such as asymmetric pupil responses and also neuropsychological impairments such as memory deficits. Intermittent chronic exposure of workers to trichloroethylene has produced neurological effects similar to those found in acute exposure situations. Studies on the neurological effects of acute trichloroethylene inhalation in animals have produced results similar to these events. There are several case studies and acute accidental ingestion of varying amounts of trichloroethylene by humans (Byers et al 1988: Lagakos et al 1986). Some other peoples from this population did show residual damage to the facial and trigeminal nerve measured by decreased blink reflex indicating damage to cranial nerves V and VII.
Manganese (Mn) is well known and ubiquitous among the welding population, to induce parkinsonism, even if there are no family history or other exacerbating or exposure factors to explain their movement disorder. It is uniquely and unusually displayed in early age, versus idiopathic Parkinson's disease.
Mr. Dortch also delineates under the heading of "additional significant reports" an elaborate report on carcinogens by the US Department of Health and Human Services released on January 31, 2005, the following COC were listed to be known to be human carcinogens.
1. Benzene.
2. Vinyl chloride.
The following COC were listed as reasonably anticipated to be human carcinogens:
1. 1-4-dichlorobenzene.
2. Naphthalene.
3. Polychlorinated biphenol (PCB).
4. Tetrachloroethylene (PCE).
5. Trichloroethylene (TCE, TCA).
"A report, assessing a human health risk of trichloroethylene, released by the National Academy of Sciences in 2006, was prompted because government agencies and scientific community have engaged in much debate over the quality of some data and how to assess the information. Several government agencies requested a study by the National Research Council. Data that provide independent guidance and scientific issue to support objectively and scientifically balanced health risk assessment for trichloroethylene.
"This extensive report is included as reference 7." "Taken from that report includes in the reference 7 are following key excerpts" dopamine pathways of the central nervous system are critical for cognitive and executive functions. Studies show effects of trichloroethylene on serotonin neurotransmitter system Dopaminergic consequences likely contribute to motor deficits associated with trichloroethylene."
"The case report observation ...... also described the loss of dopamine neurons in substantia nigra pars compacta (the hallmark of Parkinson's disease) after intraperitoneal injections of trichloroethylene.
"A biological basis for trichloroethylene's potential contribution of Parkinson disease had been suggested by (Rieder et al 2002) to be based on the formation on the potent dopaminergic neurotoxin that could be found endogenously after exposure to trichloroethylene. Of note, trichloroethylene breaks down fairly easily and quickly in the vinyl chloride, a very well known and established human carcinogen. (In the study from the University of Kentucky and published in the annuals of neurology online version December 21, 2007, the full study is included as reference 4).
"Trichloroethylene is a probable risk factor for Parkinson's disease and parkinsonism. Based on the study of workers in an industrial plant and from animal experimental the chemical has been identified as an environmental contaminated by the EPA.
Please refer to Mr. Dortch's composed (VA CLAIM SUPPORT REPORT INFORMATION FOR MICKEY F. DORTCH).
It is also important to state the fact that Mr. Dortch suffered from young-onset Parkinson's disease, which is even more uncommon, and not seen as often as, the idiopathic more common form in those over 50. The fact that most of his pre-military and post-military environments were relatively devoid of any toxic exposures, further support his claim that his neurodegenerative diseases (Parkinson's disease, Lewy Body Dementia, Neurotoxin induced depression) have more likely than not, been directly caused by has presence at Kelly AFB during the early 1990's.
Full-blown parkinsonism usually takes close to 20 years to clearly manifest. In the most unfortunate, then it can progress further to Lewy Body dementia and depression, 5-10 years after the PD is evident.
Mr. Dortch fits the above category based upon review of his Phoenix MEPS, in service, and post service medical records.
The 6 agents documented at Kelly AFB in elevated levels in his vicinity of most concern and focus are the follow;
1. TCE, TCA
2. Mn Manganese
3. CS2 Carbon Disulfide
4. Vinyl Chloride
5, MIBK
6. The collective class of PCBs
The next page details how a young man from Phoenix entered the AF without any MEPS waivers or remarks on his physical. Upon transfer to Kelly AFB he began experiencing increased sick call visits for Upper Respiratory System complaints (URI without any cultured or antibiotic responsive empiric viral, fungal, protist or bacterial pathogens). Also he began suffering, during his time at Kelly many gastrointestinal problems, such as nausea, vomiting, dyspepsia and diarrhea. Mr. Dortch also during the early and mid 1990s while at Kelly AFB, besides his URI, airway irritation and GI symptoms of a constant and unexplained pattern, had episodes of neurologic dysfunction to include vertigo, headaches, cranial nerve palsies and ophthalmoplegia and memory and mood disturbances.
No concrete explanations were ever provided to him during his numerous sick call visits at Kelly. He was never referred to the appropriate specialists, after numerous presentations for the same 3 areas of injury and illness (ENT/Pulm, GI and neurology). This is medical protocol for GPs to defer to specialists, if after 1-2 times the patient returns or fails to improve, in regards to certain organ systems etc. More often than not, he was simply seen by a nonphysician extender (NP or PA) and never saw a GP MD/DO to evaluate his chronic and plaguing symptoms. Symptoms only which he began experiencing or exacerbated when arriving at Kelly AFB.
Phayringitis, asthma, gastritis with nausea, vomiting, nausea and weight loss are all common toxidrome symptoms secondary to organic solvents and/or heavy metals. His nystagmus, vestibular dysfunction and mood/memory decline are further evidence of a toxidrome from heavy metals and organic solvents common to industrial degreasing, painting, cleaning and welding.
As is common in PD, it takes sometimes 6-20 years for enough dopaminergic destruction to take place before overt tremors, bradykinesias and rigidity set in noticeably.
Mr. Dortch entered active duty 1985, free of any GI, ENT, Pulmonary, Neurologic and Psychiatric illness or injury. His JAN 21 1985 MEPS (PHOENIX AZ) essentially granted him a clean bill of health (Dr Stephen Toth, MD). Please see the second tab with included MEPS document.
Once he arrived at Kelly AFB in 1990 he began presenting to sick call for repeated GI (gastritis, nausea, vomiting, diarrhea), ENT (rhinosinusitis, pharyngitis, coryza/ red eye), Pulmonary (reactive airway episodes or chemically triggered asthma) and Neurological (vertigo, headache, lateral gaze nystagmus).
During the span of 2 years 1990-1992 while at Kelly AFB, he was never referred to the appropriate specialists for repeated presentations of symptoms with unknown etiologies. Often seen only by PAs not even physicians let alone gastroenterologists, neurologists, psychiatrists, ENT or pulmonologists.
His VA SUPPORT CLAIM toxological and geographical report data coincides with his GI, ENT, PULMONARY and NEUROLOGIC symptoms.
It is my opinion he was suffering a toxidrome, from a synergy of the listed neurotoxic agents (TCE, TCA, PCE, CD, MN and VC) who have been known to irritate the GI, RESPIRATORY and CNS systems.
I have conducted an exhaustive medical and safety literature search and included it under tab 4. All medical data supporting his claim of early onset, toxin induced parkinsonism, Lewy Body dementia and depression has been included and the most pertinent portions highlighted for your ease of review.
I have also read, researched and analyzed the safety data via MSDS sheets and previous cases and news releases of TCE, MN, VC, CD induced neurologic disease and ENT/GI irritation. These have been included under tab 5 with all the most supportive data highlighted for your review.
Mr. Dortch's healthy entry into service (MEPS 1985 Phoenix AZ), and then a subtle toxidrome manifested at Kelly AFB, via his frequent GI, ENT, RESPIRATORY and NEUROLOGIC ailments (see tab 2 highlighted sick call SF 600s) coincide with his temporal and physical location on an instigation with known neurotoxic, carcinogenic and GI/RESP/EYE/ENT irritating noxious agents.
His VA CLAIM SUPPORT and CD with valid references have been included and explain more than anything else, how he became debilitated at such a young age. His illness has no age consistency nor pre or post military toxic exposures to account for the rare event of early onset parkinsonism.
His Kelly AFB associated sick call visits manifested go, ENT and PULM complaints (toxidrome) and neurologic symptoms. This is where the nexus and clinical manifestation of, what now renders him physically, cognitively and emotionally infirmed and progressively worsening, started.
His chronic toxic exposure (Kelly AFB years) was starting to create the neurodegenrative diseases (PD, LBD) that take 6-20 years to fully express themselves clinically. Every included document, I submitted has been read analyzed and highlighted in support of his claim, to include his medical records and the general medical and scientific literature.
Thus to deny him a service connection based off all the presented evidence is negligent at best. He has no ability to gain or sustain any employment and will most likely decompensate physically, cognitively and emotionally. No cure for PD, LBD or toxin induced depression currently exists.
I OPINE THAT HIS NEUROLOGIC ILLNESS (PD AND LBD) AND DEPRESSION, IS MORE LIKELY THAN NOT, DIRECTLY RELATED TO HIS KELLY AFB SERVICE AND TOXIC EXPOSURES. ALL THE INCLUDED EVIDENCE IF READ, CLEARLY SUPPORTS THIS CLAIM.
Sincerely;
Dennis B. Barson, D.O., CMRO
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