Physician letters

Physician letters of support for VA service connected claims:

Suggestions an attorney had for a physician to read when you ask for their help in a letter of support are below. This is an absolute must to get accomplished otherwise the VA will most likely throw your claim out. Notice the 50/50 probability the doctor has. The doctor must also be assured he/she will not have to testify in any hearing the VA has.

• 1. In regard to the medical issue, an example of a rationale that would be acceptable would be: “Mr/Ms. (last name) first noted this medical problem during his military service.  He/She continued to experience these symptoms for many years before he/she was diagnosed with the medical problem.  Because the symptoms were first experienced in service and have been continuous, it is at least as likely as not that the in-service symptoms were the first manifestation of his current condition.” 

  2. The VA is going to ask the doctor for the ASTDR/CDC paper or other medical journal on UDMH which confirms his stated link of your medical problem to UDMH. It has to be an official document not some opinion someone posted on the internet. The physician has to state he has read the medical literature document and refer to it in his letter as being the link to your problem. My neurologist in his letter added the statement right next to the more likely than not statement “The medical literature shows neurological effects following exposure to UDMH. Article attached”

  3. Physicians must state that other medical tests have been performed to rule out diabetes, b12 deficiency, etc if you are applying for peripheral neuropathy. If applying for any other medical issue the same reasoning applies : What other tests have been done to rule out other causes for your medical issue.

  4.  In a separate note: Thank the physician for their time. Again, make sure the physician knows that his/her medical statement has to only be a 50/50 probability, and his/her reading of the submitted medical literature is sufficient to support his her medical statement. His or her expertise will not be questioned. Please also be aware, the physician will not be asked to testify in a deposition or a trial. Your statement is all that (Veterans Name) asks of you.

  5. If the physician is going to be speculative in his answer this will not help you. Statements such as: There is the possibility the veterans medical problems are connected to the veterans work around toxic chemicals but I am no expert in this field. This is a useless physicians statement in the eyes of the VA. The physicians statement to be helpful must just state the facts as written above. Nothing less and nothing more.

  6. Write the letter yourself and bring it with you to your medical appointment with supporting documents. Most physicians do not have the time nor the desire to write letters and then sign them. Tell the physician if he/she does not agree with the letter and documents you brought to them please do not to sign them. Plain and simple. Find another physician who is willing to help you make your case if needed with the material facts you have presented. Note: You will most likely be charged an extended visit cost by the physician to review and sign your document.

Below is a explanation from another website (sorry I can not remember what one to give the proper acknowledgment). However, this can be shown to the physician as an explanation on how and why the wording is critical.

Below is an example of a letter from a physician and how it maybe structured to show he or she understands what they need to convey to the VA in support of your case.

Dr. xyz MD

specialty

organization

street adress.

city, state, zip

Veterans Administration

street

city, state, zip

Re: Vet name

To whom it may concern,

I had been treating Mr. or Ms. Vet metastatic kidney cancer issues since 20??.  Upon review of Mr. or Ms. Vet medical treatment records  from service and civilian clinics I have made the following conclusions.

1.  Mr. or Ms. Vet service discharge DD214 form shows he was a Missile Facilities Technician Or PTS at a Titan II Nuclear Missile complex assigned to the 571 Strategic Missile Squadron  at Davis Monthan Air Force Base in Tucson Arizona from 1962-1965.

2.  The Titan II Nuclear Missiles used a toxic carcinogenetic fuel known as to Aerozine 50 which was 50% Hydrazine and 50% Unsymmetrical dimethylhydrazine (UDMH).

3.  The U.S. Air Force released findings of a study that was completed in 1983, which indicated that out of five missile sites tested for toxic UDMH, three of the silos had concentrations that would have failed the threshold limit value/time weighted average exposure rates currently in place today for Air Force and civilian workers.  The UDMH concentrations in some of these cases were double the current threshold limits.  The toxic sample study also did not account for a 24 hour work shift which was normal for these USAF Titan II Missile Launch Crews. The actual UDMH toxic concentrations were re-calculated based on the correct ACGIH procedure and were up to 8 times the current NASA/USAF/NIOSH/ACGIH  Time Weighted Averages (TWA) of 10 ppb. Pertinent pages of the DM AFB Bioengineering Document attached. See Titan II Missile Veterans Health and Wellness Website for more information on the proper TWA calculation.

4.  In March 2006, the medical journal “Epidemiology” published findings from a cohort study, "Estimated Effects of Hydrazine Exposure on Cancer Incidence and Mortality in Aerospace Workers," in which findings suggested an increased risk of colon and lung cancer (Article attached). In the appendix of the same study indicated two more studies by the USAF on N-Nitrosodimethylamine (NDMA) (an oxidation byproduct of UDMH) toxic vapors in the Titan II Missile complexes N-Nitrosodimethylamine [62-75-9] (NDMA) is another oxidation byproduct of UDMH. As previously shown the 1983 Davis Monthan AFB Bioengineering Titan II missile complex study on UDMH and NDMA showed NDMA was present in the Titan II missile underground complex. Contamination from NDMA was also called out in USAF reports that the UCLA study had for their study of hydrazine at the Rocketdnye plant in Los Angeles, CA as being widespread contamination in the Titan II missile complexes. Appendix from that study attached. The 2012 ACGIH listed NDMA as a kidney cancer causing chemical. Attached is the page from the 2012 ACGIH manual and the appendix from the UCLA report.

5. In a second cohort study of Rocketdyne/ Rockwell/ Boeing workers, a significant increased risk of kidney cancer among employees exposed to high levels of TCE (RR=4.90) was observed and the test for a dose-response trend was also significant. Page 8 of 32 of the following document http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2791455/ . Attached is the chemical list of inventory for the Titan II Missile complexes in which it also describes PCE as being used at the missile complexes. Reported health effects linked with trichloroethylene (TCE), tetrachloroethylene (PCE), benzene, and vinyl chloride (VC) exposure. Reported health problems in people of all ages from working with TCE and/or PCE include Kidney Cancer. Titan II veterans at many Titan II missile sites during the 1975 time frame had to take drinking water out to the Missile sites as the well water at many sites was considered contaminated.  http://www.atsdr.cdc.gov/sites/lejeune/tce_pce.html

6.  In another Veteran Board of Appeals case the following was again brought to light about Titan II Missile Veterans exposure to toxic chemicals. https://www.va.gov/vetapp23/Files6/A23014490.txt “The examiner noted that medical literature documents cases of kidney cancer and numerous other types of cancers after exposure to Titan II missile fuel chemicals. In an April 2021 addendum, the VA examiner noted that according to medical information on chemicals, the breakdown of the Titan II missile propellants includes Aerozine 50-50, which is made of 50% unsymmetrical dimethylhydrazine (UDMH), 50% hydrazine, and oxidizer-inhibited fuming nitric acid (IRFNA). He noted further that a US Air Force 392d Aerospace Medical Group document from 1962 reported that there are eight extra toxic chemicals. from the release of UDMH or Aerozine 50-50 into the atmosphere, caused by spilled fuel from refueling or leaky missiles, and the Veteran would have potentially been exposed to several toxic chemicals, including formaldehyde (HCHO), hydrogen cyanide (HCN) ammonia (NH3), dinitrogen tetroxide (N204), methylamine (CH3NH2), cyanic acid (CHNO), carbon dioxide (CO2), carbon monoxide (CO), and N­itrosodimethylamine (CH3) 2 NH. In a May 2021 addendum, the VA examiner noted that the Veteran was exposed to the toxic chemical, Aerozine 50-50, which is known to increase the risk of kidney cancer and has been implicated in numerous cases with veterans with similar exposures. He reiterated his opinion that the Veteran’s kidney cancer is related to his job maintaining the Titan II missile silo during active military service. There is no contrary medical opinion of record.” https://sites.google.com/site/titan2vetshealthandwellness/1962-medical-conference-by-usaf-titan-ii-icbm/combustion-and-degradation-products-of-n204-udmh?authuser=0

Based upon research information provided here it was more likely than not (more than 50% probable) that the Mr. or MS.Vet’s metastatic kidney cancer and subsequent death were due to his exposure to Aerozine 50 (50% Hydrazine/50% UDMH) and their breakdown toxic byproducts from his USAF service in the Titan II nuclear missile complex..

Sincerely,

Dr. xyz MD