1. Camp Lejeune Contaminated Water Training J. Rice Portfolio Sample

2. Getting Started
The purpose of this training is to prepare LHI contractors to evaluate Veteran and Civilian claims related to contaminated water at Camp Lejeune, N.C. This training will cover the following:
Background of Camp Lejeune Situation
Understanding Exam Concepts & Your Role
Overview of Trichloroethylene, Perchloroethylene, Benzene and Vinyl Chloride
Understanding the Appointment and Order Request Information
Reviewing Documentation
Literature Review
Writing Your Opinion
Helpful Tips and Additional Assistance
*The examples used in this training are fictitious and not intended to represent any specific person.

3. Background on Camp Lejeune
Marine Corps Base Camp Lejeune is a United States military training facility in Jacksonville, North Carolina. The water supply at Camp Lejeune was contaminated between 1953 and 1987 with a number of chemical compounds that have been identified by scientific organizations as being associated with the potential for developing certain diseases. These chemicals include:
Trichloroethylene (TCE)
Perchloroethylene (PCE), also known as Tetrachloroethylene
Benzene
Vinyl Chloride
© 2017 Logistics Health Incorporated. All rights reserved.

4. Your Role
You will be reviewing claims for Veterans with verified service at Camp Lejeune during the period of water contamination. The Veteran is claiming service connection for a specific disease/condition. You must:
Evaluate the available body of evidence (Veteran’s medical records and available research/literature)
Determine the likelihood that the claimed disease is related to the Veteran’s exposure to contaminated water while serving at Camp Lejeune
Provide a detailed medical rationale for your determination
Your rationale must develop a clear system of reasoning based on the medical evidence that led to your determination
at least as likely as not: Determine if it more likely then not (50% or greater probability) that the condition was caused by their time at Camp Lejeune. Other risk factors to consider. (age, gender, lifestyle, occupation, etc.)
Gen. John A. Lejeune

5. Civilian Exams
At times you may receive a request to evaluate a civilian file. Civilians living and working on the base were also at risk to contaminated water exposure. In these cases, you can eliminate other possible military exposure risks for the claimed condition.
You will be provided with private medical records for review. Additionally, the dates of exposure will be pre-confirmed and can be assumed to be accurate.

6. Legal Exam Legal exams for receiving benefits only
You are not a patient advocate
You must be a neutral third party
You will answer only what the VA asks on the Order Request
Your medical opinion is only one piece of information used for rating purposes
The VBA will determine if benefits are granted or not
Facilitator script:
Understand  what VA wants / needs on these exams 
Be Objective – you are not an Advocate.
Must act as a neutral third party
For these exams the Veteran’s condition is already medically established. You must determine if the condition is more likely then not caused by their exposure to contaminated water exposure at Camp Lejeune then other factors (age, family history, gender, lifestyle, other exposures in life, etc.)

7. Presumptive Service Conditions
The following eight conditions are presumptively associated with >=30 days of service at Camp Lejeune during the period of contamination:
Kidney Cancer
Liver Cancer
Non-Hodgkin’s Lymphoma
Adult Leukemia
Multiple Myeloma
Parkinson’s Disease
Aplastic Anemia and other Myelodysplastic Syndromes
Bladder Cancer
You will see exams for conditions not on this list. The VA will review each claim individually and determine if it a Camp Lejeune Contaminated Water medical opinion is needed. We will provide an opinion for the condition the VA specifies on the VA Order Request.

8. Presumptive Service Connection
The Department of Veterans Affairs (VA) has deemed that Veterans, former reservists, and former National Guard members, who served at Camp Lejeune for no less than 30 days (consecutive or nonconsecutive) between August 1, 1953 and December 31st, 1987, and who have been diagnosed with any of eight associated diseases, are presumed to have incurred or aggravated the disease in service for purposes of entitlement to VA benefits.

9. This decision does not automatically imply that a Veteran is entitled to benefits if they have one of the eight conditions and served >= 30 days at Camp Lejeune. The presumption is rebuttable. The following information comes from CFS
Evidence which may be considered in rebuttal of service incurrence of a disease listed in §3.309 will be any evidence of a nature usually accepted as competent to indicate the time of existence or inception of disease, and medical judgment will be exercised in making determinations relative to the effect of intercurrent injury or disease. The expression “affirmative evidence to the contrary” will not be taken to require a conclusive showing, but such showing as would, in sound medical reasoning and in the consideration of all evidence of record, support a conclusion that the disease was not incurred in service.

10. You must evaluate their other risk factors beyond contaminated water exposure. After reviewing their additional risk factors, you must determine if their condition was more likely caused by their contaminated water exposure, or the combination of their other risk factors.
CLCW >= 50% Probability
At least as likely as not
CLCW < 50% Probability
Less likely as not
To establish connection of condition to Camp Lejeune service, you must evaluate the Veteran’s risk factors outside of Camp Lejeune exposure, and determine if it more likely then not (50% probability or greater) that the condition was caused by their time at Camp Lejeune, then other risk factors the Veteran was exposed to.
© 2017 Logistics Health Incorporated. All rights reserved.

11. Agents of Exposure Perchloroethylene (PCE), or Tetrachloroethylene
Synthetic chemical widely used for the dry cleaning of fabrics and for metal-degreasing operations
According to CAS, PCE “is reasonably anticipated to be a human carcinogen.”
PCE has been associated with increased risk for :
esophageal cancer
cervical cancer
liver damage
kidney damage

12. Agents of Exposure Trichloroethylene (TCE)
An Industrial Solvent. PCE in ground water degrades into Trichloroethylene.
Believed to have entered the water from spills and leaks from underground storage equipment
According to Chemical Abstract Services (CAS) of the American Chemical Society, TCE “is reasonably anticipated to be a human carcinogen.”
EPA assessment of TCE “Carcinogenic to humans” by all routes of exposure
TCE has been associated with increased risk for :
Liver Cancer
Kidney Cancer
Non-Hodgkin’s Lymphoma
Prostate Cancer
Multiple Myeloma

13. Agents of Exposure Benzene
Benzene is used in the manufacture of industrial products such as detergents, explosives, synthetic rubber, and plastics. Benzene is found in gasoline and trace amounts are found in cigarette smoke.
According to CAS, benzene “is known to be a human carcinogen”
EPA assessment of benzene “a known carcinogen for all routes of exposure”
Benzene is associated with increased risk for:
lymphatic cancer
hematopoietic cancers
leukemia
specific histologic types of leukemia
chronic lymphocytic leukemia
myelogenous leukemia
multiple myeloma

14. Agents of Exposure Vinyl Chloride
A colorless gas used in the production of polyvinyl chloride (PVC). PCE in ground water degrades into Vinyl Chloride.
According to CAS, vinyl chloride “is known to be a human carcinogen.”
EPA assessment of vinyl chloride: “statistically significant elevated risk of liver cancer, specifically angiosarcomas”
Vinyl chloride is associated with increased risk for:
liver cancer, especially angiosarcoma of the liver (high correlation)
cancer of:
brain
lung
lymphatic system
hematopoietic system

15. Levels of Exposure
The exact extent of the contamination at Camp Lejeune cannot be documented with certainty, but it is known that a few highly contaminated wells supplied water to the Tarawa Terrace and Hadnot Point systems and that the contaminated wells were in operation for multiple years. The contaminant concentrations in the water-supply system varied because well pumping was cycled (the contaminated wells were not operated continuously, so there were fluctuations in contaminant concentrations).

16. Levels of Exposure
The fundamental problem in estimating exposure to contaminants in the water supply systems of Tarawa Terrace and Hadnot Point quantitatively is the lack of information on water quality and treatment system operation during the period of contamination. There is no water quality data for the period before the 1980s. This leaves a 40-year period for which the extent of water-supply contamination is undocumented.

17. Pathways of Exposure
Although most attention has focused on the ingestion of contaminated water, additional exposure pathways were possible. Such routes of exposure include the inhalation of chemicals that have volatilized from standing water in toilets and faucets. There also was dermal exposure from showering and washing.
Exposure via inhalation and dermal absorption of VOCs from water used for household purposes has been shown experimentally to account for as much exposure as that from drinking the water. (NRC, 2009)

18. Timeline of Exposure
The water supply at Camp Lejeune was compromised from August 1st, 1953 until December 31st, 1987.

19. Levels of Exposure
“Workers are exposed to much higher levels of TCE, PCE, benzene, and VC than are people who drink (CL) contaminated water. Therefore, the health problems seen in people who worked with TCE, PCE, benzene, and VC may not be seen in people who drank contaminated water” [ATSDR Reported health effects linked with TCE, PCE, benzene, and VC exposure in people, updated January 16, 2014].
End of Sample: This is not the full presentation and serves only as a sample of work.