I had already been keeping myself entertained with texting in laws. They had asked how I was doing to which I responded that instead of feeling like I had been hit by a pickup truck I now only felt like I had been hit by a cachectic octogenarian riding a Segway. This was met with immediate demands to know if they had found the person who did this to me:
As well as their response:
It’s such a warm and fuzzy feeling to know that there are those willing to indignantly do violence on my behalf. I was in the beginning of another one of my favorite parts of this process: recovering my energy. Yay.
I learned after surgery a few years ago that recovery can be as trying as time in the hospital in its own right. I have to fight getting frustrated about not being able to do things I could just a week before. Every task seemingly requires more energy than it used to. When I spoke about this with my pulmonary doctor he told me that it is important to push to a certain extent. He in no way seemed to be advocating for being reckless. He just explained that without pushing the limits I would not regain lost strength and that everything would remain more difficult.
Of particular interest regarding my current pulmonary doctor: this is an individual who I had worked with a few times while assisting our trauma hospital. I didn’t know him well but we immediately recognized each other during my first appointment. He immediately impressed me with how he made time to listen to my concerns and remained engaged (a stark contrast from my previous pulmonary doctor.) I also learned that he was classmates with the doctor that is the director of the department I work in. When I commented about it to the doctor I work with he immediately showered the pulmonary doctor with praise. Apparently this pulmonary doctor had been top of his class in an Ivy League school after graduating with a separate degree that he later abandoned in order to take on a new career helping people. As with most answers from my director to my inquiries: specific examples and citations nearly in APA formatting were given.
Trying how to figure out how to push oneself without going overboard is proving challenging. The simple act of making it through a shift is trying. During the first few days I have frequent spells of dizziness, lightheadedness and room spinning. As I occasionally check my heart and oxygen rates I find my heart is racing to keep up. I get frequent inquiries if I am ok. It’s hard to say everything is fine when my face is either pale or flushed which even my patient families are now bringing to my attention. While my first inclination is to push through everything and say nothing is wrong it would not placate my coworkers who are ALL trained in critical care. You just can’t get one over on them.
While resting at home I had been considering how to deal with the seemingly frequent response that my issues are anxiety driven coupled with exercise induced asthma with bronchospasms (periods in which I have more difficulty breathing than usual) that so far no one has yet been able to prove. It occurred to me that having seen this response several times now it appears to be part of how the medical response game is played. I also started thinking about how I could find a way to change the game as that my ability to effectively argue anxiety while struggling to breathe would be near pointless. That got me to thinking about looking into how other veterans might be responding to clinicians telling them that their breathing troubles were psychiatric.
I found a military times article that quoted a doctor from New York arguing for more invasive testing of pulmonary compromised veterans. He points out that in absence of getting a pulmonary diagnosis clinicians are then left to psychiatric approaches which is inappropriate. My heart fluttered for a moment reading that and I don’t believe that it was because of breathing troubles this time. The article also stated that the same doctor feels that many veterans are being incorrectly diagnosed with asthma and exercise induced bronchospasms. Another flutter. 4 items were listed to assess including checking a 2 mile run time from before deployment to after, allergy testing, fractional exhaled nitric oxide testing and impulse oscillometry testing with the conclusion that irregularities in those area may suggest need for a lung biopsy. I already know that I have problems with the first two items and had no knowledge of what the other two tests are let alone having had them. I decided to look for any scholarly articles by this doctor on this topic.
An article from the doctor quoted, Dr Anthony Szema, was readily available and in a strange twist of fate I didn’t have to pay anything to read it. Its assertions were that pulmonary damage appeared to be related to burn pits, sand, and IED (bomb) blasts. A test was cited stating that this team has been successfully able to duplicate similar pulmonary symptoms to my own in lab mice. The segment on allergies bore a number of similarities to my own allergy testing. There was a more comprehensive list of items to assess veterans at the end. The ninth item was a recommendation to encourage veterans that their symptoms are not psychological. Also included were two potential treatment options of unknown human efficacy. A separate paper cites on of them increasing respiratory functions of the affected mice.
My present plan is to first take this I formation to a few trusted individuals to see what they think. I feel that as an experienced ICU nurse I have a decent ability to critically analyze an article. At the same time I am aware that I have strong emotions and a desire to have a definitive diagnosis and plan. It would be ideal to make sure that my desire for answers isn’t overriding my better judgement. I also decided to take advantage of the counseling services my organization offers. I started to feel more and more that if I could show a willingness to explore the idea of anxiety I might be able to get more consideration towards other diagnoses from more open minded clinicians. It might take at least one bullet out of the chamber to those who would be more dismissive. It also might be helpful for me as that this shit is pissing me off.
**********
Dr Google is a dangerous consult. It is easy to read into cases that don’t pertain to you. You might read about a treatment that another patient had whose kidneys failed and needed dialysis. You then realize that you have kidneys and you don’t want to need dialysis. Further scrutiny frequently reveals that the patient was on their way to kidney failure already. If you want to drive you doctor into early retirement then frequently site google in response to treatment options. I use the internet frequently in my work and feel that I can effectively navigate it for my patients but I do have to consider the risks of navigating it for my own health as that my objectivity could be compromised. While taking into account this concern I also have concerns that if my trouble is service connected then I would belong to a small subset of the population.
Veterans and service members account for a small portion of the living US population. Most recent estimates appear to be around 7%. Of that many service members have not deployed. Of those who have deployed an even smaller percentage of individuals report difficulty breathing. Acceptance of new medicine is based largely on groups that an be studied in large enough quantities to reproduce results. Peer reviewed double blind studies tend to be the preferred standard. I find it reasonable that doctors have difficulty recognizing new problems that have not been widespread enough to observe. To make matters more challenging: if a patient is improving then we frequently have less cause to keep working them up.
Few people want a test that they don’t need. Reputable doctors don’t want to order unnecessary tests either. If a person seems like they are improving or at least aren’t getting worse then most doctors I know are going to want to wait until the patient deteriorates enough to warrant more aggressive testing. When I was hospitalized for severe pneumonia a few years ago the doctors knew relatively quickly that I had pneumonia and fluid in my chest. An argument could be made that they could have figured the nature of my pneumonia sooner if they had stuck a needle in my chest and pulled out some of the fluid for testing. Doing so might have made my hospitalization a little easier but that same needle could have failed to show anything important while risking me for bleeding, infection and a collapsed lung. Sometimes it’s hard to know when to pull the trigger on more aggressive tests and treatments.
**********
Burn pits in military combat zones ran constantly. I never was in them but always around them. The smoke and fumes that they produced would slowly waft over everything around them and one quickly learned to get used to them. Whenever I was riding on a Blackhawk or Chinook I could tell by the smell that we were almost there (coupled with a smell of rotting waste akin to an overloaded porta potty.)
I never had the privilege of burn pit detail. Other soldiers would comment about how individuals charged with keeping out hazardous items would throw lithium batteries into the flames to watch them pop. Reports include burning of plastic bottles, hazardous materials, medical wastes, styrofoam and anything else available all by using jet fuel as an accelerant.
Sand in Iraq is unlike American sand. It’s so fine it’s like walking through confectioners sugar. It gets into everything. A recent study found that Sand in Camp Victory in Iraq had titanium as well as several other metals on an extremely small level. Since adding it as an inclusion factor it has been found in the lungs of affected veterans. Diagnosing it is problematic as that it reportedly requires an electron microscope which is not commonly available. Current speculation is that the metals and sands are rendered airborne via anything from sand storms to vehicles driving through and stirring it up.
Improvised explosive devices are the most current link under scrutiny, particularly in soldiers with traumatic brain injuries (TBI.) Diagnosing TBI after the fact seemed problematic in 2005. VA physicians had to rely heavily on what you tell them (subjective data) while lacking physical evidence (objective data) as that it is often months after the fact and no imaging at the time was capable of offering visible data. Various articles state that previous blast injuries clinicians evaluate would involve significant trauma like pneumothorax (air in the chest but outside the lung that causes the lung to collapse.) Recent theories are that blasts can damage the alveoli (tiny grape like clusters where oxygen and carbon dioxide enter and exit the blood.) The incendiary chemicals like phosphorus are also noted to be of concern to pulmonary tissue.
(The above should image is from our base FOB Marez. The sand surrounding it was part of our half mile trek for food each meal. The chow hall was destroyed before Christmas, 2004 by a suicide bomber whom detonated at lunch time.)
This article is the only one I am aware of that takes all of the abnormalities I have and puts them into 1 potential disease presently being coined “Iraq/Afghanistan War Lung Injury.” The available articles I have been able to access don’t presently hypothesize as to the overall morbidity or mortality. Successful diagnosis appears to require a lung biopsy which is where veterans like myself seem to fall into a catch-22. I am not sick enough to meet any present widespread standards that a physician would want to refer me to a cardiothoracic surgeon. Few CTS surgeons would want to perform the said biopsy without a clear and accepted indication. Even if I can find someone to do it I would still have to find a way to get insurance to pay for it. I would really like to not have any of these episodes at work as that it would put me out in front of my coworkers in a position in which I wouldn’t be able to take care of myself. I also don’t like the idea of putting them into a position in which they would have to clinically help one of their colleagues. At the same time I look back at not being able to move my hands and everything appearing blurry and ask myself if I would rather have the next (and at the current trajectory probably worse) episode at home or surrounded by people who can handle breathing events.
**********
To my colleague: thank you for being willing to help me out as I’ve been working through this. I know many of you want to move on to higher level skill jobs like NPs but this is the only place I want to be. You all being willing to help me out has made it possible for me to keep doing what I love. At the same time please be aware that I recognize that it takes extra work for you to do that. It’s a hard admission to need help and makes my pride hurt a little but I truly am grateful. I don’t like the position it puts all of you in; I highly value pulling my own weight. If it comes down to it I am prepared to move on.
Burn pits, Sand and IEDs 
You must be logged in to post a comment.