CRNE VCE exam - Canadian Registered Nurse Examination Updated: 2023

On a accurate autumn evening, by a golf course at the Greenbrier resort, I sipped a rye Manhattan to try to trip my heart into an arrhythmia. Scout’s honor, this was for legitimate medical reasons, though not quite in line with the doctor’s advice.

For seven-plus years, I’ve sporadically awakened in the night with my heart bludgeoning the walls of my chest. These are not panic attacks—they’re cardiac episodes, always triggered by drinking, sometimes severe enough to think I might die. A few years ago, when I confessed this to a doctor, she referred me to a cardiologist. I never followed up. It seemed complicated to work out the insurance. More to the point, I didn’t want to know.

But that morning, at the Greenbrier’s medical clinic, a heart monitor had been affixed to my chest. The nurse swabbed my skin with alcohol, then slapped it on, an hourglass-shaped device the size of a soup spoon, angled below my collarbone toward my ribs. To me, the next step was self-evident: I needed to get myself drunk in its presence. The doctor, for the record, disagreed. But if I didn’t get drunk—on top-shelf liquor, in the warm embrace of a luxury West Virginia hotel—then how could we possibly figure out what was wrong?

I’d come to the Greenbrier on assignment, to learn how the other half lives. I figured it would be like Dirty Dancing, and basically it was: quaint ballrooms and formal dinners. A man singing Sinatra in the lobby. Resplendent mountain views. The resort offers leisure galore—falconry, trout fishing, an infinity pool, carriage rides—but the activity I’d come to try was the “executive health exam.”

A two-day comprehensive physical, the executive health exam is ordinarily the preserve of elites. For $3,500—not billable to insurance—you get a battery of tests, plus substantive face time with a doctor, who evaluates your overall health. The majority of top hospitals offer these exams, alongside many clinics, spas, and resorts. Corporate employers are the main customers—fancy physicals are nice perks for executives—but private individuals sometimes buy them, too. (The Greenbrier comped mine.) If you ask a doctor, the goal is early detection of health issues. If you ask me, the goal is learning if you might imminently die.

That’s how I wound up at the golf club, 31 years young with a cardiac monitor tucked beneath my shirt. It was late September, a chill under the wind, a peach sunset glowing behind the dark spines of distant mountains. Anxious, I sipped my liquor—a poison that promised to flush my heart out of its hole, whip it into a panic, and leave it flailing around my rib cage for several lonely hours of the night. I dreaded that. But maybe the monitor would find nothing. Maybe I was the picture of health.

The week I booked my executive physical, Kim Kardashian was in the news. She’d Instagrammed about getting a $2,500 full-body MRI scan that promised to detect budding cancers, and the medical community went berserk. It’s bad preventive medicine, various doctors told the media. These scans can cause real harm.

The criticism is this: When you start poking around a presumably healthy person, you’re going to find abnormalities. Probably, they’re benign—things that never would have become problems, that didn’t need to be known. But once an issue is identified, people feel compelled to follow up. They get tests—sometimes harmful ones involving radiation—that cost significant time and money, drain hospital resources, and usually amount to nothing in the end.

An executive health exam is not an MRI body scan, but the critique is basically the same: that it’s bad to run unnecessary tests. In a standard physical exam, care is tailored to the patient’s risks—lung screenings for certain types of smokers, colonoscopies for adults over 45. But executive health exams, critics say, run tests for the sake of running them, without regard to a patient’s real needs. Sometimes, these exams catch issues early. But more frequently, they scare people who aren’t ill.

“Executive Physicals—Bad Medicine on Three Counts” is the title of a scathing 2008 opinion piece in the New England Journal of Medicine that I read before my trip. The author, a physician from Minnesota, blasts executive physicals as elitist and points out that their outcomes aren’t necessarily better than a standard physical exam. The article calls executive health “a whimsical extravagance that satisfies certain people’s need for exclusivity” and “almost a parody of . . . high-cost, low­return procedures.” It concludes that these exams are inequitable and ineffective, “a perfect example of what American medicine should be working to expunge.”

The night before my exam, cocooned in a toothpaste-colored Greenbrier suite, I contemplated the possible outcomes. The worst-case scenario was obvious: that I’d exacerbate inequities in the American healthcare system by participating in an exclusionary form of care, while simultaneously learning that I’m dying. In the best-case scenario, I’d receive an excellent physical—the kind that helps the richest Americans live, on average, ten to 15 years longer than the poor.

But the likeliest scenario, I feared, was that I’d undergo two days of testing and come out with a list of possible health concerns that—while probably nothing—might also be cancer. There would be increased 2 AM scrolling of WebMD. I already felt the dread.

My exam began with bloodwork, four dark vials sucked from a vein in my arm. Then I met with the doctor, who took the most thorough health history of my life. She was a young woman with long auburn hair. It fell across her lab coat in waves.

“Do you have a primary-care doctor?” she asked, and I cringed as I confessed that I don’t. For about an hour, I sheepishly narrated my health concerns, via charming anecdotes like these: Once, a doctor found a gallbladder polyp and told me I should keep track of it, but I never went back. And: A cash-only gynecologist once swabbed for a uterine issue and told me to call in two weeks. By the time I did, four months later, her practice had closed.

The doctor asked if I was up to date on a Pap smear (no), when I’d last been vaccinated for tetanus (no clue), and what I was doing to manage stress (pouring myself into work). Then we arrived at my heart, so I explained the genetic situation—valve issues on both sides, the kind that strike people down—while the doctor scribbled with furrowed brow. “We are going to follow up on this,” she said, which filled me with both terror and relief. That’s one benefit of the executive physical: Ghosting isn’t an option. These tests would be done. I was a captive inside a resort.

In fact, the testing commenced posthaste. Through a side door of her office, the doctor led me to a small exam room, where a nurse had prepared an EKG. “This measures the electrical workings of the heart, as opposed to the plumbing part,” she explained as she strapped 12 electrodes to my chest. Atop the same table, the doctor did a quick Pap smear. While at it, she stuck a finger up my butt, checking for something called “fecal occult blood.”

From there, I changed rooms. In the semi-dark, a sonographer slathered me with gel for an abdominal ultrasound, followed by an echocardiogram and imaging of my carotid artery. Afterward, I had a chest x-ray, then lunch: two small chicken-salad sandwiches packaged in a blue-and-green striped box, eaten in the coffee room while Antony Blinken discussed a hostage release on Fox News.

By this point, I was an hour ahead of my itinerary, but the nurse still saw me right away. First came my ear wash, a highlight of the day: warm, abrasive liquid pumped gently but persistently toward my brain. Then she tested my hearing, breathing, and orthostatic blood pressure. All of it was simple and nice.

Last came the heart monitor, the day’s sole point of friction. Apparently, for the two weeks I would wear it, I needed to keep a special phone within 30 feet of me at all times. As the nurse laid this out, I blanched. Lugging around two phones for 14 days? How would I remember, and would I look weird with a strange object adhered to my boob, and what if the phone lost charge, and what if I’m really sick? What I actually asked was “Do you see a lot of heart monitors on younger patients?” “We’ve had several,” she replied, her face revealing nothing at all.

Since I was years overdue for a tetanus shot, she offered to supply me one right there. I asked to push it to tomorrow. In a couple of hours, I was headed to the Greenbrier’s gun club for skeet shooting. I needed my arms to be spry.

In response to my photographs of the Greenbrier, here is what friends have said: “It’s like Barbie lived at Graceland instead of Elvis,” and “It’s like Norman Rockwell and Tucker Carlson collaborated on a tarot deck,” and “It’s faux neoclassical mixed with Memphis mixed with rococo,” and “I like it. It’s really exciting.” All of these strike me as correct.

Leaving the clinic, I hopped on an elevator that spat me into an eddy of hotel-room doors, none of which happened to be mine. When I tried another floor, I got lost, wandering a bewildering zone of ballrooms and grand staircases and cascading chandeliers. It was a fabulous place to be trapped. The decor was delirious—carpets and wallpapers in pinks, greens, blood reds, and blacks, arranged into florals, stark geometries, and abstract designs. Finally, I confessed to an employee that I was lost. “That’s okay,” he replied. “It’s only a 1.1 million–square-foot building that isn’t symmetrical.” Then he led me down some hallways toward my room.

That afternoon, I had no obligations at the clinic—just skeet shooting and a plan to drink myself into medical distress, which commenced at the golf-course bar. Over the next several hours, I would migrate to the upper lobby, where, surrounded by dark mahogany and framed drawings of long-dead Presidents, a suited bartender shook me a gimlet. Learning of my predicament, he reassured me that his heart has a hole in it, but he’s still here.

Alone at the Greenbrier, I passed the evening texting various factoids to my friends. These messages concerned my health, the textiles, the retired congressional nuclear bunker buried beneath a wing of the hotel, and the sweet gun-club attendant who called me “ma’am” the whole time I shot clays. But primarily, the texts were about Babydog, the rotund English bulldog that belongs to the Greenbrier’s owner, West Virginia governor Jim Justice. Among her achievements, Babydog was the star of the state’s underperforming Covid-vaccine campaign (called “Do It For Babydog”), and she allegedly predicted the outcome of Super Bowl LV.

While I texted at the bar, an email from the Greenbrier Clinic popped up on my phone. My fate had arrived: Some of the test results were in. Immediately, I deleted it. To wipe my brain, I grabbed a diabolical concoction called a “lemon haze”—Hennessy, tequila, limoncello, and Cointreau—and wandered onto the balcony into the night. There, in a rocking chair around a tabletop fire, I listened to a drunk man who claimed to be an ex-cop describe the scene of a notorious Charlottesville murder. Then I got into bed, fell asleep, and woke at 4 AM with a splitting headache and racing heart, but not the arrhythmia I’d sought.

This was the worst possible outcome. I was tired and hungover, with no relevant data for the heart monitor. My fitness assessment was scheduled for 9 AM.

Returning to the clinic, I felt nervous. Somewhere inside, behind a baby-blue door, my test results awaited review. Throughout my fitness and nutrition consults, the 11 AM discharge meeting loomed. When the hour came, I marched somberly to the doctor’s office, suppressing the stray impulse to flee.

We began with my bloodwork, which actually looked fine. I’m not anemic, my glucose is normal, my cholesterol is excellent, and my kidneys work well. I was deficient in B12, but the doctor promised to supply me a shot before I left. My hearing and breathing were good, and the chest x-ray found nothing substantial. Then we arrived at the locus of my dread.

The heart stuff was anticlimactic; the doctor didn’t have much news. The tests that came back looked “reassuring,” but the most telling one—the monitor—wouldn’t be reviewed until I’d worn it and mailed it back. Ordinarily, I’d have dwelled in dissatisfaction. But I was distracted. The abdominal ultrasound seemed bad.

Alarming yellow highlights marbled the printout of results; these were the doctor’s areas of concern. First were the gallbladder polyps—not one but two. In the majority of people, these are benign, she said. But they could become cancerous. I would need to monitor them to see if they grew.

Then came the “lesion on my spleen.” On the paper, beneath a highlighted streak, I saw a word that ended in “oma.” Oh God, I thought. That’s bad. In the dark pantheon of omas—sarcomas, melanomas, lymphomas, carcinomas—I knew of none that I wanted to have. Whatever a “hemangioma” was, it was probably how I would die.

The doctor, however, thought otherwise. While the ultrasound couldn’t precisely diagnose it, the spleen lesion was probably fine, akin to a birthmark or a mole. “If that’s what it is, it’s not anything we should worry about,” she said. “But we should follow it.” I swallowed hard.

I should have been prepared for that moment, since it was precisely what the critics had said; executive health exams often catch things that aren’t bothersome, that are probably benign but possibly deadly, and therefore beget pointless worry and additional care. I tried, briefly, to feel indignant. But were the lesion to turn cancerous, I’d be positioned to detect it early. I was sort of grateful to know.

At the end of my exam, the doctor pronounced me “very healthy,” and rationally I knew this was true. Still, the splenic “oma” ran skittery around my brain. I thought about it as I exited the clinic and entered an unnaturally pink restaurant for a fried-green-tomato sandwich. And that’s when I returned to my heart. It was the arrhythmia, if anything, that would kill me—although at least I was addressing it now. I’d submitted to copious testing. The monitor sat in judgment atop my chest.

By far, the executive health exam had been the best medical experience of my life. No doctor had ever spent so much time with me. No clinic had ever felt so warm. And the testing—for all its naysayers—seemed pretty targeted to my concerns. Had I gotten this care in the real world, it would have involved three or four visits to various far-flung locales, all on separate days. I would never have done it. I’d have just sat at home worrying about my heart.

Now, having tasted upscale preventive medicine, I didn’t want to go back. I dreaded a future of bleak fluorescent clinics and chaotic strip-mall urgent-cares. Couldn’t I receive all of my healthcare at a florid and maximalist resort, surrounded by foggy mountains while golfing and dining and shopping and shooting clays? Of course you loved the executive health exam, responded the cynical region of my brain. It’s a luxury product that you can’t regularly have, that most people could never afford.

But the goat cheese on my sandwich was so creamy and I was eager for my afternoon hike, where the sun would dribble over the wildflowers and the mountain air would be crisp. My nagging conscience quieted. I returned to brooding about my death.

This article appears in the November 2023 issue of Washingtonian.

PHOENIX - It's a phrase people often see in news reports about deaths – that results from toxicology tests can take weeks, even months.

A quick search on the web shows similar verbiage used in reports on the death of hip-hop star Mac Miller, as well as singers Prince and Michael Jackson.

As of Nov. 15, 2023, toxicology reports for late ‘Friends’ actor Matthew Perry remain pending.

With that in mind, some are wondering why there's such a delay in releasing results from toxicology tests.

Here's what you should know.

What are toxicology tests?

(Photo By Eduardo Parra/Europa Press via Getty Images)

According to an article published by WebMD in 2012, there are different types of toxicology tests. For this article, we are talking about forensic toxicology testing, or toxicology tests that are performed after a person dies. Such tests are also known as "postmortem drug testing."

In the WebMD article, it's noted that forensic toxicology testing is part of an autopsy report. A medical professional who worked at a San Diego hospital at the time the article was published defined the report from forensic toxicology testing as "the result of the lab procedures identifying and quantifying potential toxins, which include prescription medications and drugs of abuse, and interpretations of the findings."

You mentioned other types of toxicology tests. What are they?

In the WebMD article, it is noted that another type of drug testing is called "clinical toxicology," or drug testing ordered by a medical professional, such as an emergency room doctor if a patient shows up with signs and symptoms of drug overdose or abuse.

Other types of toxicology tests, according to the article, include workplace drug testing and athletic drug testing, the latter of which is used to detect banned substances or performance-enhancing substances.

An article published by the Cleveland Clinic also lists other ways toxicology tests are used, such as during a criminal investigation as a way to collect potential evidence of a crime.

What do they collect for toxicology tests?

Containers of urine samples for testing. (Photo by Herman Lumanog/Pacific Press/LightRocket via Getty Images)

According to the WebMD article, blood samples are collected from different areas of the body, such as from the leg and heart, in order to account for different concentrations of drugs. The comparison of different concentrations can, according to an expert, boost accuracy. In addition, urine and tissues can also be collected for testing.

Afterward, the article states that the specimens are sent to a toxicology expert for testing. If drugs show up in the testing, more sophisticated tests will then be done, and experts will then determine a number of things, including whether the drug (or drugs) contributed to a death or directly caused a death.

What do the results tell us?

As mentioned above, the WebMD article states that experts will determine, based on data they received from toxicology tests, whether a drug (or drugs) contributed to a death or directly caused a death.

However, the same article also states there are times when a toxicology report presents a not-so-clear-cut picture of what happened. According to an expert interviewed in the article, about 2-5% of death cases are deemed to have an indeterminate cause of death. 

Why do they take so long?

In a 2015 document, officials with the Wisconsin Department of Justice state that several factors contribute to the time it takes to finish a toxicology report, including:

1. The steps taken during a test
2. Testing of specimens in batches for efficiency purposes
3. Technical review of data after it has been processed by an analyst
4. Accuracy review of a toxicology report by an analyst and a supervisor

Meanwhile, the WebMD article also lists other factors in the lengthening of the time needed for a toxicology test to be completed, including

1. The amount of specimens that need to be tested
2. The need for more tests, as information surfaces about the possibility of another drug being involved in a death
3. Sending off specimens to specialized laboratories to confirm positive drug tests

How long does it normally take in the U.S. to complete a toxicology test?

(Asad Zaidi/Bloomberg via Getty Images

According to a 2021 report published by the U.S. Department of Justice, the average turnaround time, or the average duration to complete a toxicology case, is 33.3 days, with public toxicology labs taking an average of 55.2 days, and private labs taking an average of 4.1 days.

Meanwhile, in its 2022 Annual Report, officials with the Maricopa County Office of the Medical Examiner state that on average, toxicology tests are done 15 days from the date of examination, with 96% of the tests being completed within 30 days.

WASHINGTON (SOA) — There’s a growing national conversation about toxic chemicals known as PFAS, as federal health bodies take action to address contamination and assess health risks. We first reported on a new study linking a PFAS chemical to testicular cancer earlier this week. Now, in an exclusive report, we examined new data about PFAS found in servicemembers’ blood and new efforts in Washington to get care and compensation for those exposed.

Retired Air Force firefighter Kevin Ferrara remembers working with AFFF, firefighting foam we now know was made with PFAS, toxic forever chemicals that have been tied to a host of health problems including cancer.

"They told us it's soap and water and we believed it," Kevin Ferrara told Spotlight on America. "We slathered ourselves in this stuff, it came into contact with bare skin and eyes, nose and mouth."

Today, Ferrara has made it his mission to help firefighters understand the potential risks from their exposure to that foam. He told us firefighters come to him and ask about the health risks. "Usually the first question I get is, 'Am I going to get cancer?'" said Ferrara.

Answering those questions is complicated, but new studies are shedding light.

As we first reported earlier this month, a first-of-its-kind federal study performed the largest examination of PFAS exposure and testicular cancer to date, by looking at the banked blood of Air Force servicemembers. It found those employed in fire protection had elevated concentrations of PFOS, a PFAS chemical, in their blood. Higher blood levels of PFOS were linked to testicular cancer.

It's the latest in a growing body of research tying PFAS to health effects, but despite widespread use of firefighting foam, and suspected contamination in the groundwater of hundreds of military bases, exposure to PFAS is not widely considered a service-connected injury, and sources tell Spotlight on America there's a lack of understanding and uniformity among medical providers.

"We're calling PFAS, the new Agent Orange," said Kevin Ferrara. "It's frightening because you look at what the DoD has done to veterans that were exposed to Agent Orange, they strung them along for decades until they finally recognized it."

Congress mandated that the Department of Defense offer blood tests to military firefighters to look for PFAS chemicals in 2020.

The first results were reported to Congress this year. Spotlight on America dug through the data, finding that more than 9,100 firefighters opted for a blood test in 2021.

You can read the full report to Congress below.

We took the results to PFAS researcher and former West Virginia University Professor Dr. Alan Ducatman.

"When you get to the 95th percentile, which is 5% of people, those exposures get to be quite high," Dr. Ducatman said. "There are some people with extraordinary exposures, and there's every opportunity to figure out what those people are doing and to think about the jobs and what may be leading to those exposures that could be backtracked, and public health could be improved."

Most of the blood tests performed, about one third, were servicemembers in the Air Force. The PFAS detected most often in the serum was PFOS, which was found in 95.6% of the samples.

Overall PFAS geometric mean blood concentrations ranged from a high for PFOS at 3.1 nanograms per milliliter (ng/mL), followed by PFHxS (2.8 ng/mL), PFOA (1.1 ng/mL), and PFNA (0.42 ng/mL).

In a 300-page report, the National Academies of Sciences suggested that 20ng/mL of PFAS in blood is serious enough to screen patients for signs of testicular cancer and other health effects.

Among the DoD's blood test results, levels of just one PFAS chemical at 150 ng/mL. That's more than seven times higher than the NAS designated level that could indicate potential health effects.

Still, the full extent of exposure in the military community at large is unknown.

Blood tests are only offered to active duty and reserve firefighters, not veterans or other servicemembers who may have worked with AFFF.

The VA's web site does not recommend blood tests, saying most Americans have PFAS in their blood and saying "blood tests cannot be linked to current or future health conditions."

Congressman Dan Kildee (D-MI) doesn't believe people understand the risk to veterans. He created the Congressional PFAS Task Force in 2019.

"We have not seen, whether it's in the VA or the DOD, we haven't seen the kind of urgency that we think should be applied to PFAS contamination," Rep. Kildee said. "I just don't think the the federal government is doing anywhere near enough."

For now, even with the results of a blood test in hand, we discovered military firefighters are fending for themselves.

Kevin Ferrara said he's spoken with firefighters left confused by their results.

"A lot of times they say, the doctor looks at them and says, 'I have no idea what this data means. Good luck.'" Kevin Ferrara said. "That's not what these firefighters need to encounter when they see a physician."

Dr. Alan Ducatman told us it's unreasonable to expect that all doctors are PFAS experts, but it's important for medical monitoring systems to be in place. "It would be good to get a cadre of doctors for the military and for communities who have had these elevated exposures who do understand the problem and who can help those community members."

Spotlight on America obtained guidance the military gave to its practitioners offering PFAS blood tests, telling them to inform patients “any follow-on health care or medical evaluations based on the PFAS laboratory result must be sought from their private healthcare at their own expense.”

Congressman Kildee calls that "unconscionable."

He's introducing legislation called the Veterans Exposed to Toxic PFAS Act, which would require the VA medical system to treat those cases as duty-related, to include high cholesterol, ulcerative colitis, thyroid disease, testicular cancer, kidney cancer and pregnancy-induced hypertension.

But the bill has not advanced.

"When a person puts on the uniform of the country, they accept certain risk," Rep. Kildee said. "But we also say to them, if you get injured, we're going to take care of you. We're gonna have your back. And the very idea that we have to pass legislation to codify a promise that I think is implicit is very frustrating to me."

It's frustration shared by Kevin Ferrara.

"Congress can make change within a day with a swipe of a pen," he said. "Every single day that Congress is sitting on this and arguing over whose name's going to be on the bill, who's going to sponsor it, who's gonna vote on it? We have veterans out there every day that are suffering from PFAS, and they're dying from this stuff."

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The VA told Spotlight on America it's reviewing new studies about PFAS. You can read our full Q&A with the VA below:

Q1. (VHA) Is the VA aware of the federal study that linked PFOS in service members to testicular cancer ? What is the VA’s response to that study? Is there discussion about how those findings may inform the treatment of military members?

A1. We are currently reviewing this study. Veterans who feel as though their health has been impacted by exposure to PFAS during their military service are encouraged to file a claim for disability benefits. These claims are considered on a case-by-case basis.

Q2. (VBA) Is the VA aware of legislative efforts to designate PFAS exposure as a service-connected injury? What is the VA’s response to those efforts, and does it plan to comply with the law if passed?

A2. We are closely monitoring the research regarding exposure of service members to PFAS. PFAS are synthetic chemicals that are contained in many products such as fire-fighting foams (aqueous film forming foams (AFFF)), clothing, furniture, food packaging, and may be contained in drinking water and certain foods.

While no presumptions have been established to date for any specific medical condition based on exposure to PFAS, a presumption is not required to establish service connection. VA makes decisions on claims based on exposure to PFAS or a specific source of PFAS, such as aqueous film forming foams, on a case-by-case basis. For example, for a Veteran filing a claim for disability due to exposure to aqueous film forming foams, VA reviews the facts and evidence such as the types, levels, and duration of exposure (if known), onset and nature of claimed medical condition(s) and other factors to determine if disability compensation is warranted. If there is an approximate balance of positive and negative evidence, VA gives the benefit of the doubt to the Veteran.

Our general policy has always been that disability compensation can be granted if a Veteran has a current disability that is related to his or her military service including disabilities related to in-service exposures like PFAS. Any Veteran who feels that military service has negatively impacted his/her health is encouraged to submit a claim for disability compensation.

Q3. (VHA) Does the VA recommend that military firefighters receive blood tests for PFAS, in light of the study finding that those employed in fire protection had elevated levels of PFOS?

A3. We are currently reviewing scientific information related to PFAS blood testing and the utility of such tests in a clinical setting. It has been established that a blood test for PFAS gives only a snapshot of what is in the body at that time; it cannot inform on when an exposure occurred, source of exposure, or current or future health outcomes. We will continue to discuss this issue and will review additional information as it becomes available. We are also actively working to address research gaps related to PFAS-related health outcomes in the following efforts:

A collaboration between VA’s Health Outcomes Military Exposures (HOME) program, Central Arkansas VAMC and Naval Health Research Center is leveraging assets from the Millennium Cohort Study to investigate PFAS levels in military firefighters (occupationally exposed) and construction workers (occupationally unexposed) as identified by military occupational specialty (MOS) codes. The study will also investigate correlations between PFAS levels and cardiometabolic outcomes and biomarkers.

A pilot study collaboration between HOME’s Exposure Science Program, Defense Centers for Public Health – Aberdeen and the National Institute for Environmental Health Sciences is to investigate and track PFAS exposures in active-duty firefighters via dried blood spots. Correlations with biomarkers of effect will be evaluated.

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Spotlight on America also posed a list of questions about blood testing to the Department of Defense. You can read their full responses below:

1) What is being done to analyze blood test results on a wide scale?

Response. Since October 2020, PFAS testing has been offered to all DoD firefighters during their annual physical exams as directed by Congress (Section 707 of the National Defense Authorization Act for Fiscal Year 2020). The PFAS testing offered to each DoD firefighter is directed in DoD Policy, “DoD Manual 6055.05-Occupational Medical Examinations: Medical Surveillance and Medical Qualification, Section 5.13”, available at https://www.esd.whs.mil/Portals/54/Documents/DD/issuances/dodm/605505m.PDF?ver=3u-UoR7v7wydz-RIKQkI_Q%3D%3D. Currently, an individual’s PFAS levels cannot be used to predict adverse health effects and no occupational screening values for PFAS have been established. Exposure assessments and health studies are under way by organizations such as the Department of Health and Human Services (DHHS) Centers for Disease Control and Prevention (CDC) and the Agency for Toxic Substances Disease Registry (ATSDR). They may inform whether screening values can be determined for PFAS in the blood of the general public and for occupational settings. Results from our analysis of DoD firefighters is included in the response to the second question.

2) Can your office provide data on what has been collected and found?

Response. PFAS levels in blood are the result of exposures from all sources: environmental, occupational, and use of consumer products. The presence of PFAS in DoD firefighter blood does not tell us how, where, when, or for how long a person was exposed to PFAS, and whether it was from firefighting or other sources of PFAS. The following six PFAS were tested in the blood of DoD firefighters from October 1, 2020 through May 1, 2023: perfluorooctanoic acid (PFOA); perfluorooctane sulfonate (PFOS); perfluorohexanesulfonic acid (PFHxS); perfluorononanoic acid (PFNA); perfluoroheptanoic acid (PFHpA); and perfluorobutanesulfonic acid (PFBS). Additional PFAS were added, beginning in May 1, 2023. Summary statistics for the first year of DoD firefighter blood testing can be found on https://www.health.mil/Reference-Center/Reports/2023/02/14/Perfluorinated-Chemicals-PFCs-Contamination-and-First-Responder-Exposure.

Analysis of results from samples collected from the second year of testing (October 1, 2021 through September 30, 2022) is currently underway. In addition to similar summary statistics, the DoD will include some initial trending information between the first and second year of offering tests to DoD firefighters.

Additionally, the DoD is currently planning to have future blood samples analyzed using the CDC’s analytical method. This will allow the DoD to reevaluate PFAS being analyzed and consider additional PFAS analytes to better align with those being analyzed by the CDC. The CDC indicates that their scientists found four specific PFAS (PFOS, PFOA, PFHxS, and PFNA) in the blood of nearly all of the people tested, indicating widespread exposure to these PFAS in the U.S. population. CDC data suggest that over 98% of Americans have detectable levels of PFAS in their blood. The data tables showing PFAS blood testing results for the general population since 1999 can be viewed at: https://www.cdc.gov/exposurereport/.

3) What examinations are underway?

Response. The DoD is collaborating with other Federal agencies that are leading efforts associated with the completion of environmental and occupational exposure assessments, risk assessments, and health studies. The ATSDR and CDC’s National Institute for Occupational Safety and Health (NIOSH) are conducting health and exposure studies to understand PFAS exposure pathways from environmental and occupational PFAS sources, and whether these exposures are linked with potential health outcomes. The results of these studies will inform the development of exposure assessments, occupational exposure limits and medical surveillance requirements for the DoD. In addition, the Department will update its guidance to DoD healthcare providers when ATSDR revises their PFAS clinical guidelines.

4) How many of these blood tests have been performed?

Response. DoD records indicate that in Fiscal Year (FY) 2021, 10,208 DoD firefighters were offered a blood test for PFAS as part of their existing annual firefighter occupational medical surveillance exam. Of these, 9,104 DoD firefighters chose to have their blood tested and 1,004 DoD firefighters opted not to have their blood tested. A complete analysis of accurate (FY2022 and beyond) blood testing data is ongoing and unavailable at this time.

Q: For a year, my boss at work was harassing me. It got so bad that I filed a police report. Now I have a lawsuit against him and the company. They have demanded a mental exam. Isn’t that just more harassment?

T.B., Chino Hills

A: The California statute on point provides that a mental examination of a party may be ordered when his or her mental condition is placed in controversy in a civil case [CCP Section 2032.020(a)]. Unless the parties agree, leave of court is required to request such an exam, and there has to be a showing of good cause [CCP Sections 2032.310(a) and 320(a)]. Good cause may well be found if you have said that as a result, you suffered mental anguish and/or emotional distress. In sum, if you put your mental state into issue, you may well have to undergo the exam.

Hence, my thought is that you sit down with your lawyer and discuss what it means to have a mental exam by the other side. Ideally, you knew going into your lawsuit that a mental exam could be required. Learn what kind of questions may be asked, and whether there will be testing of some kind (for example, multiple choice). Other inquiries include how long will the exam will take, can it be recorded or videotaped and can your lawyer be there? Note that a report will likely be issued, which your lawyer can review and challenge. And you should no doubt have your own expert to explain the severity of your anguish caused by the former boss’s misconduct.

Q: Just what is an independent medical exam? I have serious injuries caused by a bad driver who went through a red light. Now, as part of the lawsuit, do I have to go to their doctor’s office to be examined?

N.D., Newport Beach

A: It is not uncommon in personal injury cases, particularly where significant monies are sought, that the injured party is required to undergo an independent medical exam conducted by the doctor selected by the other side. At the risk of sounding a bit cynical, the word “independent” is a bit of a stretch. The doctor retained by your opponent wants to be credible, wants to be believable, but it is his or her job (if possible) to downplay your injury or injuries, and/or cast some question or doubt about them.

The medical exam can be recorded. Your lawyer can be there as well, and observe. Keep in mind you are alleging that you suffered physical injury as a result of the accident, and you may be arguing that you are going to have future medical care as well. Part of the lawsuit process is what we sometimes call “dueling experts” — yours and theirs. Your doctor is going to emphasize the nature and seriousness of the harm you have suffered; as noted, theirs may try to counter the seriousness.

Talk this out with your lawyer. Know what to expect at the independent medical exam. The report issued by the other party’s doctor may be suspect, and a challenge to it (and the other party’s expert) is part of your lawyer’s job.

Ron Sokol has been a practicing attorney for over 40 years, and has also served many times as a judge pro tem, mediator, and arbitrator. it is important to keep in mind that this column presents a summary of the law, and is not to be treated or considered legal advice, let alone a substitute for real consultation with a qualified professional.