Dr. Benitez Question and Answer Session on Fly Ash Spill

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What is medical toxicology? And, approximately how many toxicologists are there in the United States?

Well, medical toxicology is the specialty of, the physician specialty in toxicology. Toxicology itself deals with how toxic substances are in different types of substances, by that I’m including things like snake venoms, spiders, medications, chemicals - anything. And so we deal with assessing a patient. We’re looking at, getting history, doing physical examinations, doing laboratory evaluations, and then trying to put it all together… to [see] was it causing a problem, treating them, and discussing that, obviously, with other specialists as necessary. So that’s what the specialty is. And there’s roughly, three- [or] four-hundred of us in the country, so there’s not a humungous amount. In Tennessee we have three, which is kind of nice compared to some states that don’t have any.

What does a medical toxicologist do?

We’re another medical specialty – just like a cardiologist deals with hearts and a pulmonologist deals with lungs, and so forth, we deal with the effects of toxic substances on the body, and basically anything that’s a poison, we take care of.

What is the definition of poisoning?

Just about anything can be a poison. A good example that I frequently use is people think that, well, “water’s safe but lead is not,” and I say, “well, water also can be a poison” because it’s really the amount of anything, including water, that can be a poison.

Why should toxicologists be a part of this screening program? How will the program benefit from your involvement?

Well, the benefit of having a toxicologist is that we deal with anything that’s a poison and anything can be a poison - whether it’s a dust, whether it’s a particular chemical, or whatever in this situation - so we can start putting the risks together. I mean, just because you were exposed to a particular chemical or substance doesn’t by itself mean it’s going to cause a problem, but it has to do with the amount that’s getting into your system [and] whether it be just as a onetime exposure or chronically over days/ weeks/ months/ years, that it can be a problem. So we can start looking at what do we need to do. For the care of some of these kinds of poisons, somebody may need a special type of doc[tor]. If it’s something that’s affecting the lung primarily, they may end up needing a pulmonologist. If it’s something that’s affecting the kidneys primarily, they may eventually need a kidney doc[tor]. But that depends on if they even get up to the point of risk to those particular organs. So the main thing we need to do to start with is: what is the risk, what are the substances and what is it causing, so we can detect if there’s any problem.

Why should people living near the fly ash spill sign-up for this screening program?

Well I think there’s that potential risk. Everything, from at least a calculation standpoint and what’s been measured so far, appears that it’s going to be a relatively low risk, but what we’ve been hearing is that they still want to ask a doc[tor], as in a physician, “What exactly does this mean to me and my family?” And this is the one thing we can do. We can get a history, do a physical exam, do some appropriate testing for the things that do need to be tested, including some screening things –like for lung function, kidney function, etc.- so that we can see if there’s a problem now or not. If there isn’t one, we at least have …baseline levels –baseline function of your lungs, your kidneys, etc.- and then if-and-when we need to do a repeat exam, whether it’s myself, or my partners, or their own family doctor, we’ve got a baseline against which to measure.

What sort of information will you be providing to those who go through the screening program? What will people know after they have been screened?

We’re hoping to at least help interpret their current medical situation; review their history as far as any kind of chemical exposures currently, in the past, work-wise or otherwise; [and] put that in the context with these baseline screenings that we’re doing as far as chest x-ray, pulmonary function, blood work and so forth, to let them know, “Okay, you look normal/you do not,” “You need further testing/you do not.” I suspect we’ll probably pick up some people that may not even know they have some other problem that may not even be related to this, and then we can obviously refer them back to their doctor. Or we may find out that they know they have diabetes or whatever the underlying medical problem might be, but they may be a little bit more out of control than they should be, and we can still help them realize that there’s other issues and they need to talk to their family doctor on those particular issues.

What do you, as a medical toxicologist, hope to learn from this medical screening?

What we’re trying to learn from this too is, well, we know the individual toxicities of a lot of these chemicals. I’ve treated, for example, a lot of arsenic cases, I’ve treated a lot of lead cases, I’ve treated a lot of patients with different types of specific chemicals. [But] there’s fairly little literature on specific toxicities from fly ash, for example. We know from previous accidents that it has not created a lot of major problems, but, again, there’s only so many accidents that occur per year, and if we collect the data at the time, we can at least get a better baseline.

Have there been similar medical screenings conducted on the health effects of fly ash? If so, will you refer to those studies? If not, how do you approach being the first medical toxicology department to be involved in this sort of program?

I don’t think there’s been a truly focused evaluation of fly ash with people in the past. They’ve obviously had disasters, [but] the presumed thought was that it didn’t cause any major problems. The people that were examined and tested for it appeared and looked okay in the short term and the long term, but, again, there’re very small numbers that have been involved in that. And so we’re hoping to expand on that field with a little bit more focus, specifically looking at the real risks from a toxicologic[al] perspective.

There seems to be conflicting information regarding the toxicity of fly ash and the potential for health effects. Where can people go to find the most accurate information?

There’s multiple sources right now. One of them is obviously to use, starting from the local and going up to the national/federal level - they can always start with the poison center. That’s where the three toxicologists in Tennessee work, that’s what we deal with, and they can always call and get the most current information that’s available. They can always call Tennessee Department of Health, for example, or even the local health department. Going to a more national level, we have a different federal agency, specifically CDC and ATSDR from a health perspective.

What does your department already know about the potential health effects of fly ash?

In general, what we’ve seen in the limited medical literature out there is that it’s a relatively nontoxic type of material. We know that, [in] the particular measurements already obtained, that the levels are actually pretty far down and that even eating a certain amount (and I’m not recommending this to anybody), but if they’re eating a certain amount of fly ash even per day, even for a little kid, over a long period of time they [the levels] would not get to anywhere where we know there’s a problem with some of these particular chemicals. So, even though, for example, arsenic was already high, even eating some of it on purpose, per se, is not going to give you enough of an arsenic level to cause a problem – IF conditions stay the same. The problem then becomes if it starts accumulating in specific water wells or that type of thing, then it could change the perimeters under which those measurements were obtained and then they would find that that could cause a problem. Hence the other reason for doing a baseline evaluation and then doing periodic evaluation to make sure nothing’s happening.

How does this screening program differ from other programs in which you’ve participated?

We basically try to get everybody that was potentially exposed to be assessed. We do, however, want to tailor it to what is the risk at hand – and that’s where it always differs. There’s a specific population/geography that’s involved in the situation as to who can get exposed, the particular substance and how it can potentially get into the person. So because of that, [we need to know] the potential for affecting people - “Is it different than what would happen if it were just in a building and it’s only an airborne type of exposure as opposed to these other roots?”

How did you decide which elements to test for in the medical screening process?

There was a long list of chemicals that basically EPA, Department of Health, etc., have been testing. We first looked at the list to see of those different chemicals or elements out there, which ones are a potential human risk. Based on that, we then looked at - based on what’s there and has some potential for human risk- how can we really assess them, measure them, and look at them. And therefore, then, we could narrow the list even further. And then the next question was, what is the best way to measure that particular chemical, because sometimes you can actually measure the chemical, but sometimes the best evaluation’s not to measure it, but to measure the effects on a particular organ or system, so this is an ‘indirect measurement,’ if you will.

What would you say to someone who is skeptical of the screening program to get them interested in signing-up?

Well, I would say that, “We’re here to help you.” All I can do is offer. If you don’t want it, you don’t want it, that’s your call. But I think we have something to offer. We can screen, look to see if there’s any potential problem, if there is one, we’ll find it, let you know what you need to do at that point, or even what I will need to do at some point if necessary, or even give them recommendations of what they need to do with their own family doctor.

Why would someone need to start out seeing the medical toxicologists [through this screening program] rather than their own personal physician?

I think some people have already seen their family physician. The problem that happens there is, again, the background of most physicians, and I’m not talking about just the family medicine but it could be essentially any specialty, is that they don’t have any really training in toxicology. So trying to put together some symptoms, some historical findings, [and] getting the depth of history that’s needed as well as the specific signs and symptoms that we’re looking for during that history and physical session – they [doctors other than toxicologists] may not obtain everything that’s needed at that point.