There are currently 22-25 million active duty service personnel and veterans (military personnel) in the United States (US). Approximately 75% of them will seek healthcare services outside of the Department of Veterans Affairs (VA) system.1, 2
Daily, military personnel experience hazardous environments, emissions, and pollution, from man-made, geographic, and natural sources.1-) They are dissipated from3,4, 6-15: aircraft refueling, burn pits, chemical plants, construction, dust storms, explosions, farming industry, generators, fires (oil wells; sulfa mines), and vehicle exhaust.
Physicians, both military and civilian, have reported that military personnel deployed to Iraq and Afghanistan have complained of respiratory symptoms and illnesses, which were not present prior to their deployment.3,4,10, 14, 16, 17 King et al reported that military personnel who were physically fit prior to deployment, now struggle to pass their required running tests.1) In addition, the medical literature is conflicting, confusing, and often lacking information on the long-term health effects and prevalence from environmental exposures. 2- 5, 8, 9, 11, 12, 16, 18, 19
Johnson et al reported, “it is crucial that non-VA nurses . be able to recognize, assess, and provide appropriate care to this population” and include in their assessment, a comprehensive “veteran- centered health history.”1
In 2013, the VA in conjunction with the Department of Defense (DOD) enacted and implemented Public Law 112-260, which required them to establish the Airborne Hazards and Open Burn Pit Registry (Registry).4,5, 7, 15, 16 The Registry was the result of many concerns by military personnel, their families, and Congress because personnel . returning from . Iraq and Afghanistan [were] reporting health problems. [due to] the burning of waste in open-air “burn pits.” 3
The intent of the Registry is to collect pertinent individual data from military personnel regarding their environmental exposures with specific attention to those deployed to Kuwait, South West Asia, Iraq, Afghanistan, and other overseas deployments in that region.3,4,12, 15, 17, 21 The VA and the DOD is attempting to, “identify the full impact of toxic inhalation exposures during military operations.” 12
Their goal is to:
determine and monitor if a correlation exists from exposures which may have “.long-term health consequences” to military personnel. 5,11,12,16,17,22
“. establish clinical evaluation protocols for exposure to burn pit emissions and other airborne pollutants [they] encounter.” 16
offer optimal medical assessment.5
keep military personnel informed regarding studies and treatment 5 and,
register them in the event they are “. eligible for disability compensation..”(17
Burn pits are the primary means used to dispose of trash and waste products on military sites overseas when other conventional methods such as incinerators, are not available. 3,11, 19 The waste products are destroyed by burning them in a large open pit typically by igniting it with jet fuel. Some pits consume 10 acres and are 50 feet deep.3,4,14, 17, 22
Waste products include 3,4,17,21,22 : batteries, chemicals, cans (aluminum, aerosol, metal cans), computers, discarded food, electronic equipment, human/medical waste, paint, plastic bottles, polypropylene, rubber, Styrofoam, tires, unexploded munitions, and wood. The emissions and by-products from combustible materials may include 3,4,6, 9, 23 : Acids, Arsenic, Carbon Dioxide, Carbon Monoxide, Cyanide, Dioxins, Formaldehyde, Heavy Metals, Hydrocarbons, Hydrochloric Acid, Lead, Sulfur, and Volatile Organic Compounds.
Hundreds of burn pits have been used during the Iraq and Afghanistan conflict while military personnel live, work, and sleep in close proximity to pits that are actively burning, 24 hours per day, seven days per week.2-4, 14, 17, 19, 21, 22 Levine reported military officials had stated, “.that smoke from the Balad pit in Iraq exposed troops to toxic emissions, including low levels of cancer-causing dioxins. Tests however had indicated there was no long-term danger.”(22 In addition, particulate matter measurements are known to have exceeded the Environmental Protection Agency air quality guideline levels limit by 100 to 1000 times that as considered acceptable. 3,4, 6, 9, 12, 14, 18
In 2009, burn pit use was prohibited by the DOD, and was used only as a last resort if no other means of waste management was available. In Iraq, by 2010, burn pits were completely phased out however, in Afghanistan hundreds of pits continue to operate. 3-5, 17
Health Effects from Exposure
Symptoms from the acute exposure from airborne emissions are usually short-term and may include 17, 20- 23: excessive coughing, black sputum production, headache, throat and eye irritation, itching, nausea, nasal congestion, and rashes.
Military personnel returning from overseas locations have complained or have been diagnosed with 1-4, 8, 10, 13, 14, 17, 18,2) : new-onset asthma, chest tightness, constrictive bronchiolitis, emphysema, fixed airway obstruction, pneumonia, sarcoidiosis, wheezing, unexplained dyspnea on exertion, and vascular remodeling. The vast majority of the medical literature currently supports new onset respiratory symptoms and diseases; however, the chronic effects remain unknown.1, 3- 5, 8, 9, 11, 12, 16, 18-20, 23
Levine reported that, “.soldiers [have] complained of respiratory problems and skin infection and in some cases believed they developed leukemia and tumors from their exposure.” 22 Smith, et al reviewed military personnel medical records and reported that, “. respiratory illness was the second most common” reported ailment since being deployed.3)
SEE ALSO: Improving Healthcare for Veterans
Szema reported, that “. soldiers deployed to Iraq were diagnosed with asthma more often.” than soldiers who were stationed stateside and that 14% of the overall visits for medical care consisted of respiratory compromise complaints. 14 Sharkey, et al reported that “.exposures to burn pit emissions have been implicated as a cause of chronic respiratory illnesses.14 Urban and Turner, recently reported there was a significant increase in cardiovascular, neurological, and respiratory conditions.17
In January 2015, the US Supreme Court made an unprecedented decision and ruled that military personnel, who think they were sickened by burn pit exposures, could file legal action against the private contractors hired to operate the pits in Iraq and Afghanistan.17, 24-26
Johnson, et al reported, “it is imperative for nurses in all civilian care settings to understand the impact that military service has on veterans’ health.” 1 Military personnel experience different conditions depending on their age, gender, and deployment locations. Each deployment is unique to them and their current health issues.1, 2, 27
Each time a nurse is assigned to a patient, they must perform an assessment.1, 28 The assessment must include, “. the physical, emotional and mental aspects of all body systems, as well as the environmental and social issues affecting the patient.” (28) Once the nurse determined the patient fulfilled military service they should include as part of their assessment, a comprehensive veteran- centered health history and ask questions relevant to the information they provided.1, 29
A veteran- centered health history should first begin by obtaining a general military history. Then, specific questions covering important subject-matter issues such as: chronic pain, hazardous exposures, homelessness, military sexual trauma, polytrauma, post-traumatic stress disorder, substance use disorder, suicidality, and traumatic brain injury can be obtained. 1, 2, 27 Once the patient has been managed, discharge instructions should include informing them of VA support services, referrals, and the Registry.1
Nurses continue to be in a unique position of assessing and educating patients regarding health issues. Today nurses should now include a veteran- centered health history as more military personnel seek healthcare services outside the VA system.
1. Johnson BS, Boudiab LD, Freundl M, Anthony M, Gmerek GB, Carter J. Enhancing veteran centered care: A guide for nurses in non-VA settings. Am J Nurs. 2013. 113(7): 24-39. doi: 10.1097/01.NAJ.0000431913.50226.83. http://journals.lww.com/ajnonline/Fulltext/2013/07000/Enhancing_Veteran_centered_care___A_Guide_for.27.aspx. Accessed June 16, 2015.
2. Keavney E. Caring for veterans- Schools of nursing increasing focus on veterans’ health issues. Advance for Nurses. 2013. http://nursing.advanceweb.com/Features/Articles/Caring-for-Veterans-2.aspx Accessed June 17, 2015.
3. Institute of Medicine (IOM). Long-term health consequences of exposure to burn pits in Iraq and Afghanistan. National Academies Press. Published October 31, 2011. https://www.nap.edu/login.php?record_id=13209&page=http%3A%2F%2Fwww.nap.edu%2Fdownload.php%3Frecord_id%3D13209 Accessed June 10, 2015.
4. Office of The Surgeon General. Airborne Hazards Related to Deployment. CP Baird & DK Harkins (eds.) Published January 10, 2013. http://www.cs.amedd.army.mil/borden/Portlet.aspx?ID=87a2edd6-da3e-4ed9-b0d2-8c1246e8f5f7 Accessed June 18, 2015
5. US Army Public Health Command. Deployment environmental surveillance program: Joint Base Balad Burn Pit. Fact Sheet 47-002-0214. Published August 4, 2014. http://phc.amedd.army.mil/PHC%20Resource%20Library/Balad_Burn_Pit_JBB_FS_47-002-0214.pdf . Accessed June 9, 2015.
6. US Department of Veterans Affairs- Office of Public Health. Sand, dust and particulates.http://www.publichealth.va.gov/exposures/sand-dust-particulates/. Accessed June 9, 2015.
7. US Department of Veterans Affairs. Report on data from the airborne hazards and open burn pit (AH&OBP) registry. Published April, 2015. 1-27. http://www.publichealth.va.gov/docs/exposures/va-ahobp-registry-data-report-april2015.pdf. Accessed June 9, 2015.
8. Abraham JH, Baird CP. A case-crossover study of ambient particulate matter and cardiovascular and respiratory medical encounters among US military personnel deployed to Southwest Asia. JOEM . 2012. 54 (6):733-739. http://www.ncbi.nlm.nih.gov/pubmed/22547122. Accessed June 11, 2015.
9. Baird CP. Review of the Institute of Medicine report: Long-term health consequences of exposure to burn pits in Iraq and Afghanistan. US Army Med Dept J. 2012. PB 8-12-7/8/9. 43-47. http://www.cs.amedd.army.mil/FileDownloadpublic.aspx?docid=2c12aea8-8adf-4591-b2c1-c8a47450fe0c Accessed June 18, 2015.
10. King MS, Eisenberg R, Newman JH, et al. Constrictive bronchiolitis in soldiers returning from Iraq and Afghanistan. NEJM. 2011; 365(3):222-230. doi:10.1056/NEJMoa1101388. http://www.nejm.org/doi/pdf/10.1056/NEJMoa1101388 . Accessed July 17, 2015.
11. Sharkey JM, Harkins DK, Shickedanz TL, Baird CP. Department of Defense participation in the Department of Veterans Affairs Airborne Hazards and Open Burn Pit Registry: Process, Guidance to Providers, and Communication. US Army Med Dept J. 2014. PB 8-14-7/8/9. 44-50. http://www.cs.amedd.army.mil/FileDownloadpublic.aspx?docid=e358fb9a-c3f2-41d6-93ef-63d352ef3b82 Accessed June 18, 2015.
12.Sharkey JM. Hospitalization and medical evacuation of Army personnel due to toxic 48 inhalational exposure – Operations Iraqi Freedom and Enduring Freedom, 2001 through Mid 2011. US Army Med Dept J. 2012. PB 8-12-7/8/9. 48-53. http://www.cs.amedd.army.mil/FileDownloadpublic.aspx?docid=2c12aea8-8adf-4591-b2c1-c8a47450fe0c. Accessed June 18, 2015.
13. Smith B, Wong CA, Smith TC, Boyko EJ, Gackstetter GD, Ryan MAK. Newly reported respiratory symptoms and conditions among military personnel deployed to Iraq and Afghanistan: A prospective population-based study. American Journal of Epidemiology 2009. 170(11): 1433-1442. doi ; 10.1093/aje/kwp287. http://aje.oxfordjournals.org/content/170/11/1433.full.pdf+html. Accessed June 10, 2015.
14. Szema AM. Occupational lung diseases among soldiers deployed to Iraq and Afghanistan. Occup Med Health Aff. 2013. 1(3):1-6. NIH doi 10, 4172/2329-6879.1000117. http://www.esciencecentral.org/journals/occupational-lung-diseases-among-soldiers-deployed-to-iraq-and-afghanistan-omha-2329-6879.1000117.pdf. Accessed on June 10, 2015.
15. US Department of Veterans Affairs- Office of Public Health. Airborne hazards and open burn pit registry. About the Registry. Updated July 31, 2014. https://veteran.mobilehealth.va.gov/AHBurnPitRegistry/index.html#page/about Accessed June 9, 2015
16, US Department of Veterans Affairs. Initial research on the long-term health consequences of exposure to burn pits in Iraq and Afghanistan. Federal Register. Published February 4, 2013. 78(23): 7860-7861. http://www.gpo.gov/fdsys/pkg/FR-2013-02-04/pdf/FR-2013-02-04.pdf. Accessed June 9, 2015.
17. Urban M, Turner F. Recent veterans from Berks and elsewhere worry about burn pit exposure. 2015. Berks & Beyond News. http://readingeagle.com/news/article/recent-veterans-from-berks-and-elsewhere-worry-about-burn-pit-exposure. Accessed July 16, 2015.
18. Morris MJ, Zacher LL, Jackson DA. Investigating the respiratory health of deployed military personnel. Mil Med. 2011. 176 (10):1157-1161. http://publications.amsus.org/doi/pdf/10.7205/MILMED-D-10-00436. Accessed July 16. 2015.
19. US Department of Veterans Affairs. Clinician’s guide to airborne hazards. Published December 2014. http://www.publichealth.va.gov/docs/exposures/clinician-guide-airborne-hazards.pdf. Accessed June 9, 2015.
20. US Department of Veterans Affairs – Office of Public Health. Burn pits (Trash and human waste exposures). Published November, 2013. http://www.warrelatedillness.va.gov/education/factsheets/burn-pits.pdf Accessed June 9, 2015
21. US Department of Veterans Affairs- Office of Public Health. Burn Pits. http://www.publichealth.va.gov/PUBLICHEALTH/exposures/burnpits/index.asp Accessed June 16, 2015.
22. Levine A. VA to look into effects of ‘burn pits’ on veterans. CNN. March 17, 2009 http://www.cnn.com/2009/US/03/17/burn.pits/. Accessed on June 11, 2015
23. Zucchino, D. Report: Troops sent waste to open burn pits. Los Angeles Times. June 24, 2014. http://www.military.com/daily-news/2014/07/24/report-troops-sent-waste-to-open-burn-pits.html. Accessed June 22, 2015.
24. Druzin H. Supreme Court allows lawsuits over burn pits, electrocutions. Stars and Stripes News January 20, 2015. http://www.stripes.com/news/us/supreme-court-allows-lawsuits-over-burn-pits-electrocutions-1.324782. Accessed July 10. 2015.
25. Hurley L. U.S. top court rejects appeals by Halliburton, KBR over conduct overseas. Reuters. January 20, 2015. http://www.reuters.com/article/2015/01/20/us-usa-court-contractors-idUSKBN0KT1LT20150120. Accessed July 10, 2015.
26. Kime P. Burn-pit, electrocution lawsuits to continue. Military Times. January 27, 2015. http://www.militarytimes.com/story/military/pentagon/2015/01/22/kbr-iraq-lawsuits-supreme-court/22158399/ Accessed July 10. 2015.
27. Harris H, Cantrell N, Keene RE. VA Nursing: Mission Possible Understanding the conflicts in which veteran’s served helps nurses provide care and achieve better patient outcomes. Advance for Nurses. 2014. http://nursing.advanceweb.com/Features/Articles/VA-Nursing-Mission-Possible.aspx. Accessed July 16, 2015.
28. Quan K. How to Perform a Head-to-Toe Assessment. Nursing Link. 2015.
http://nursinglink.monster.com/benefits/articles/184-how-to-perform-a-head-to-toe-assessment Accessed July 10, 2015.
29. Academy of nursing, CRNAs launch campaign to improve care for veterans. Advance for Nurses. Posted November 20, 2013. http://nursing.advanceweb.com/News/National-News/Academy-of-Nursing-CRNAs-Launch-Campaign-to-Improve-Care-for-Veterans.aspx Accessed on June 11, 2015
M. Thomas Quail works as a nurse at the Bureau of Environmental Health for the Commonwealth of Massachusetts Department of Public Health.