A Burning Question: VA Ann Arbor Pulmonologists Chronicle Unique Diagnosis of Veteran Suffering Burn Pit Injury

While deployed to areas of Southwest Asia, many Veterans were exposed to a multitude of respiratory hazards including military burn pits, sand and dust storms, diesel fumes, and sulfur dioxide.

The challenges associated with identifying these health problems were portrayed in The New England Journal of Medicine’s “Clinical Problem-Solving” series in which two VA Ann Arbor Healthcare System staff pulmonologists describe the evaluation and treatment of a Veteran experiencing breathing difficulty years after exposure to burn pits.

The article, titled “A Burning Question,” is a unique journal entry that walks the reader through the medical issues the patient is reporting, followed by the doctor’s step-by-step diagnosis and treatment recommendations for the patient.   

“We thought this would be a good opportunity for doctors and patients to learn about a condition that we are concerned about, that we know is out there, and is of interest to a lot of Veterans,” said Dr. Alexander Rabin, co-author of the article and pulmonologist for the VA Ann Arbor Healthcare System.

The article describes a 35-year-old Post 9/11-era Veteran experiencing shortness of breath, coughing, and a burning sensation in the airways that developed following two deployments to Iraq in 2003 and 2005.  During those deployments, the Veteran was routinely exposed to burning paper, cardboard, electronics, used medical supplies, tires and discarded food. The Veteran also helped burn human waste by igniting it with JP-8 in a 50-gallon drum. No personal protective equipment was used, and the Veteran reported coughing and phlegm production while carrying out these assignments.

The Veteran was initially diagnosed with asthma and was prescribed albuterol to use before exercise but continued to struggle even with regular use of the medication.

“There’s a saying in medicine, ‘Not all that wheezes is asthma,’” said Dr. Rabin, referring to the Veteran’s initial misdiagnosis.

Drs. Rabin and John Osterholzer, also a pulmonologist and VA Ann Arbor Healthcare System, interpreted the testing that had been performed previously on the Veteran. Compared to other people that were similar in age, the tests showed the Veteran’s lungs were only working at about 60% of the normal predicted value.

“Usually, anyone that has a predicted value of 80% or above is considered normal.” said Dr. John Osterholzer, co-author of the article and pulmonologist for the VA Ann Arbor Healthcare System. “It’s an indication that something was wrong. The pattern of abnormalities can give us some clues of what might be wrong.”

While the tests did confirm that the Veteran had diminished lung capacity, the symptoms were not consistent with asthma. A CT scan and lung biopsy were completed which showed scarring of the small airways, a condition called constrictive bronchiolitis. 

Now that the doctors had a better understanding of the injuries in the Veteran’s lungs, they were able to adjust his treatment by prescribing him new medications and pulmonary rehabilitation. After two years of treatment and therapy, the Veteran reported that his symptoms of shortness of breath and cough had significantly improved.

The doctors conclude their article by noting “this case underscores the importance of asking about a patient’s exposures, including those during military service, and pursing comprehensive evaluation in cases in which initial testing does not yield a diagnosis that adequately account for the clinical picture.”

In August of 2022, Congress passed the Sergeant First Class Heath Robinson Honoring our Promise to Address Comprehensive Toxics (PACT) Act. The PACT Act acknowledges that military deployment to Southwest Asia may have resulted in multiple types of cancer and respiratory conditions. 

To acknowledge and promote the passage of the PACT Act, Drs. Rabin and Osterholzer partnered with VAAAHS team members Dr. Deborah Heaney, an Environmental Health Specialist, and Program Manager Rachel Howard to publish an essay entitled “A Sacred Obligation: Meeting the Needs of Veterans with Airborne Hazard Exposures” in the journal, The Annals of the American Thoracic Society. 

The essay highlights the frustrations Veterans often express when they perceive that their health concerns are not being adequately addressed.  The authors describe how the PACT Act will better acknowledge and address those concerns proactively. Rather than waiting for definitive proof linking the exposures with a list of over 20 medical conditions including cancers and respiratory diseases, the PACT Act identifies them as being “presumptive” conditions that are eligible for service connections.  This and other aspects of the legislation greatly expands exposed Veterans’ access to VA health care and benefits for Vietnam, Gulf War, and Post 9/11 Veterans.

Veterans who feel they were exposed to hazardous materials or smoke during their military services are encouraged to sign up and complete the questionnaire in VA’s Airborne Hazards and Open Burn Pit Registry. 

The clinicians and researchers identified in this article participate in the Ann Arbor Site of the Post-Deployment Cardiopulmonary Evaluation Network (PDCEN).  More information about the PDCEN can be found at: https://www.warrelatedillness.va.gov/WARRELATEDILLNESS/AHBPCE/network.asp