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Table 3 The environmental exposure history is the most important clinical tool

From: Expert clinician’s perspectives on environmental medicine and toxicant assessment in clinical practice

Features Clinician Quotes
Importance of an environmental history OEP It’s quite a long, drawn out question and answer process that follows no specific format, because then I go along and choose the questions I want to ask, to determine what is their alleged level of exposure and what has been the responses by their body to that exposure, and what measurements they’ve had.
IP History, history, history is the most important tool to use.
I tell the patient, it’s all in the history. Let’s spend some time getting it down and also that we’re not going to get this right in, like, the first appointment, it might take several appointments.
Because we couldn’t rely on the Australian laboratories, we stopped testing and went entirely on history.
It’s important to ask a very detailed history: occupational, hobbies, recreational, nutritional, environmental exposures, even down to things like chemical use in the house, indoor air pollution, external air pollution etc.
It’s becoming less and less value to do toxin checking and much more valuable to say is your history one of exposure to toxins and if so, what is the generalised approach that we could do, to safely protect and unload you from whatever the likely historical toxins are.
The first thing is to have an awareness of the possibility (of toxicant exposure). The second is to ask a good history. And then trying to find out what tests could be done and what treatments could be used or who to refer to.
Challenges of long consultations OEP In 90 minutes you can actually really get to understand a person and their risk of exposures and whether in fact this might be something that is related to occupational or environmental exposures.
We’re taught to ‘Take a good history’. I would challenge most doctors now, they don’t. They’ve got four minutes to see a patient, they’re supposed to see forty a day, get them in, get them out. If there’s something more complex, they say Oh, I’ll tell you what to do, let’s get a blood test done here, or Let’s see how you go, take these two pills and I’ll see you in two weeks, if you’re not better. And then they hope in two weeks, that they’re going to find more time, but they don’t.
IP 90 minutes allows me to give an hour to the history taking portion and half an hour for examination. That’s really what’s needed to conduct a proper environmental history.
With the existing system, the history-taking part has to be done in about two minutes, then you have to get the blood pressure on and the script, or the investigation printed within five minutes and then your ‘closing statement’ is six, or seven minutes. There’s no way you’re going to pick up anything deeper in that time… and it’s just enough history to work out which medication or investigation may be. So, that is a big problem.
The system isn’t really set up for doctors’ seeing patients for a long period of time. And if you claim for a long consultation, they complain.
Occupational history OEP You need to go through what is this person exposed to through the whole course of their working life.
I would tease it out, detail by detail, according to the history given, whether it was volatile organic solvents, whether it was dust, whether it was asbestos, whether it was diesel fumes. So it would become an individualized, personal question-and-answer, to get a measure of what the exposure has been, in both the long-term and in the short-term, resulting in the symptoms as expressed by the individual.
You ask people what they are exposed to, then you look at specific heavy metals or chemicals in the workplace. If somebody was making or refurbishing old thermometers, then test for mercury. If they’re working on bearings or grinding in a machine workshop, you’d probably do lead and cadmium. If they’re doing spray painting for corrosion control on a metal aircraft, then you do chromium. So you tailor it to the environment.
If you were a painter, preparing, or getting rid of lead paint in old houses, first of all you scrape the old paint and then you burn it. And if you don’t do it properly, you could be exposed to significant lead levels from the old paint.
IP If they have listed a job involving the use of chemicals, farming, soldering, or various things like that, I’ll specifically ask what personal protection they use.
I’ve noticed that some of the parents with autistic children are often very intelligent people in high end academic jobs, but not in great locations like an oil rig and things like that.
People working around swimming pools and golf course green-keepers, were getting sick with the same illness’ that the farmers in the Central Coast were getting years ago.
Place history OEP Mount Isa mines in Queensland and Port Pirie in South Australia they’ve shown quite significant spread (of lead dust), many kilometers from the stacks and waste dumps.
IP Where they’ve lived as children, renovations of houses, all those kind of things don’t actually come out unless you ask that.
You need to investigate the house for lead paint, or eating antique furniture, being bathed in an old bath.
Where were you born, where did you grow up, what were your early life experiences and exposures, or potential exposures, to toxins, what was your health like in childhood, early adulthood and adulthood?
I get them to map out on Google maps where they live, go to school and where they work. I draw a sausage shape around their home, and go half a kilometre sideways and one kilometer each end-wise and find out what is the vicinity of golf courses, industrial areas, service stations, main roads, airports, farms, bowling greens, parks…? What are the prevailing summer and winter winds? although wind direction is not useful in hilly areas. And so, we basically just stare at the map on the places where they used to live and work, and where they currently do live and work. It’s a useful thing for identifying where very sensitive people should buy houses or rent.
In relation to the Chronic Fatigue Syndrome cluster around Botany Bay, we identified hot-spots for hexachlorobenzene at Botany Bay and dioxin and PCB exposure around Homebush Bay.
What school did you go to, where was it? Lots of the toxicological assaults come from the schools, which can be situated on hills, or beside main roads and kids get plenty of exposure to cleaning agents and traffic fumes, pesticides and just about everything there. And then, half the schools seem to have the old, unflued gas heating systems through all of winter… volatile organic chemical exposure and respiratory irritants are high.
Dietary history IPs So tell me a bit about the chemical reaction you are concerned about. When was it, how long was it, how long after the exposure, the duration of the effects. What did those effects, i.e. was it gas, or the neurological. you know, childhood, behavioral. And then I just try and map it out. Then you go on to the next one. What was the next environmental reaction which your child had. And then you just slowly build up a picture of the person, and then I go through the artificial chemicals and colors, additives and preservatives as well as the natural colors, flavors, preservatives, like salicylates. And then, I go through the family history as well, that’s very important. I look for genetic predisposition and for chemical sensitivity.
If they are salicylate-sensitive, they’ll usually have a reaction to other chemicals, to artificial colors, flavors, additives. And the typical child, you know, the blond-haired, blue-eyed freckly, or red-head,...If you see someone like that and they’re of Scottish origin and they’ve got behavioral problems, that’s the first thing I go to.