RECORD OF PROCEEDINGS

IN THE MATTER OF:	DOCKET NUMBER: BC-2020-01563

XXXXXXXXXXXXXXX	COUNSEL: NONE

	HEARING REQUESTED: NO

APPLICANT’S REQUEST

1. Her record be processed through a Medical Evaluation Board (MEB).

2. Her elevated Thermoluminescent Badge results and her illness be found In Line of Duty (ILOD). 

APPLICANT’S CONTENTIONS

She was in the Regular Air Force from Jan 02 through May 10.  During that time, she reported migraines, swollen lymph nodes, upper and lower extremity weakness, rashes and a host of other medical conditions.  She joined the Air National Guard, via Palace Chase, in May 10 and was placed on extended active duty (EAD) orders from Jun 14 to Aug 16.  She returned to the Air National Guard from Aug 16 until she retired in Jun 19. 
 
When she separated from EAD in Aug 16, she was not provided the opportunity to have a final medical appointment with a medical care provider.  When she met with the medical provider, her chief complaints were not documented and she was returned to duty with no restrictions.  She should have been placed on medical hold, a Line of Duty (LOD) determination should have been initiated; and, she should have been processed through an MEB prior to her retirement.    

While on EAD, she continued reporting these symptoms and was referred to specialists, underwent two endoscopies and referred to physical therapy.  However, her primary care manager did not accomplish routine bloodwork.  Her oncologist stated her symptoms were indicators of Hodgkin’s Lymphoma and could have been diagnosed previously if lymph node biopsies or blood panels were performed.  She has provided documentation of a hospitalization from May 19, reflecting she underwent ultrasound-guided lymph node biopsies and was diagnosed with Stage IV Classical Hodgkin’s Lymphoma.

A letter from the Recovery Care Coordinator, dated 20 Oct 19, noted the applicant’s assignments included working as an Air Transportation Technician from Jan 02 until May 10 during which time she worked around C-130, C-17, and C-5 aircraft with exposure to JP-8 jet fuel in Oman in 2002, Jordan in 2003, Baghdad in 2004, and Turkey in 2009 and in burn pits while at Baghdad for six months.  In Jun 14, the applicant was placed on an EAD tour as an Enlisted Professional Military Education Instructor.  In Jun 16, she returned to the Medical Group as a Dental Assistant, during which time she was exposed to ionizing radiation while using dental X-ray equipment while performing her job assignments.
 
The Recovery Care Coordinator contends that the applicant was not afforded the opportunity to file an LOD determination prior to returning to the Air National Guard or prior to retirement.  The Coordinator also stated, due to applicant’s short prognosis it was recommended for her to expedite a retirement package instead of processing an LOD for her illness.

The applicant’s complete submission is at Exhibit A.

STATEMENT OF FACTS

The applicant is a former Air National Guard senior master sergeant (E-8), who was transferred to the Reserve Retired List, effective 9 Jun 19.  

On 23 Jun 16, according to DD Form 2697, Report of Medical Assessment, submitted by the applicant, a separation assessment was completed.  The applicant noted she suffered from migraines, pain and discomfort in her right hip and lower back pain.  She also noted she intended to seek disability from the Department of Veterans Affairs (VA) for migraines, lower back pain, anal fissures/hemorrhoids and pain in her left and right shoulders.  At the time of evaluation in Jun 16, a healthcare provider noted the applicant’s report of migraine, low back pain, right hip pain and bilateral shoulder issues.  However, there was no entry on the document to indicate the applicant was a candidate for Medical Hold or unable to perform the duties of her office, grade, rank, or rating at the time.

On 5 Aug 16, the applicant was honorably released from active duty.  Her narrative reason for separation is listed as Completion of AGR Military Duty Tour.  She was credited with 2 years and 2 months service for that period of active duty.  However, Block 18, Remarks, notes the applicant was curtailed from active duty Guard and reverted back to the Air National Guard effective 6 Aug 16.

On 11 Jan 17, the applicant enlisted in the Air National Guard for 2 years and 18 weeks.

On 9 Jun 19, the applicant was transferred to the Air Force Reserve Retired List.  She was credited with 20 years, 9 months and 10 days total service for retired pay.

On 26 Dec 19, according to documentation provided by the applicant, she was deemed a 100 percent disabled veteran by the VA for a number of service-connected medical conditions.  These included a 50 percent rating for Post-Traumatic Stress Disorder, 30 percent for migraine headaches, 30 percent for lumbosacral or cervical strain, 30 percent for impairment of sphincter control, 20 percent for limited motion of arm, 20 percent for hemorrhoids, and a 10 percent rating for limited motion of wrist.  There was no disability rating information listed for Hodgkin’s Lymphoma.

APPLICABLE AUTHORITY

All retiring members must take a comprehensive Separation History and Physical Examination  (SHPE) unless they are separating or retiring after being found unfit for continued military service through the disability evaluation process and have complete the exams in that process.  The member may elect to have the SHPE completed by a DoD medical treatment facility or the VA. The SHPE must be accomplished at least 30 days prior to the scheduled departure date, but no more than 180 days prior to the approved retirement date.  AFI 36-3203, Service Retirements, paragraph 5.1.  

An LOD determination must be initiated, whether the member is hospitalized or not, when the following occurs: death, (Regular Air Force), member is unable to perform military duties more than 24 hours due to an injury; for (Air Reserve Component), when the member incurs or aggravates an illness, injury or disease, or receives any medical treatment while serving in any duty status, regardless of the member’s ability to perform duties.  To enter the Disability Evaluation System (DES) for a duty related determination, the member must have received an ILOD determination for his or her potentially unfitting condition.  However, for members with over eight years of active service, illnesses or injuries that existed prior to service may be deemed to have occurred in a duty status for the purpose of determining disability separation or retirement by a Physical Evaluation Board if the member has at least eight years of total service; was on Title 10 active orders specifying a period of greater than 30 days at the time the condition became unfitting; and, was not released from active duty within 30 days of commencing such period of active duty under 10.U.S.C.§ 1206a (AFI 36-2910, Line of Duty (LOD) Determination, Medical Continuation (MEDCON) and Incapacitation (INCAP) Pay, paragraphs 1.6 and 1.7.3. and 1.10.2.2.2.). 

After release from active duty, members have 180 days to ensure any illness, injury or disease that was incurred or aggravated while in duty status is reported for LOD determination consideration.  When the member does not report the illness, injury or disease, the member is presumed to be able to perform military duties, does not require treatment and has no unresolved health condition rendering them unable to meet retention or mobility standards in accordance with AFI 48-123, Medical Examinations and Standards.  The only avenue for addressing previously unreported illness, injury or disease is through the VA.  AFI 36-2910 paragraph 1.7.4.

The medical unit refers members for disability evaluation when the service member has one or more medical conditions that may, individually or collectively, or through combined effect, prevent the service member from reasonably performing the duties of his or her office, grade, rank or rating; or, a medical condition that represents an obvious medical risk to the health of the service member or to the safety of other members; or, a medical condition that imposes requirements on the military to maintain or protect the member.  The mere presence of a physical defect or condition does not qualify the member for disability or retirement discharge.  The physical defect or condition must render the member unfit for duty. AFI 36-3212, Physical Evaluation for Retention, Retirement and Separation, paragraphs 1.3 and 1.4. 

AIR FORCE EVALUATION

NGB/SGPS recommends denying the application.  Based on the documentation provided, there is no evidence of an error or injustice.  The applicant’s supporting documentation reflects many medical issues; however, the complaints stem from different mechanisms of injury and nature of illnesses.  It is the member’s responsibility to report any changes to medical status to the guard medical unit (GMU) within 72 hours (DAFMAN 48-123, Medical Examination and Standards, and AFI 36-2910 Line of Duty (LOD) Determination, Medical Continuation (MEDCON) and Incapacitation (INCAP) Pay).  There was no documentation submitted showing the medical status was reported to the GMU.  Had the applicant reported the Hodgkin’s Lymphoma prior to retirement, she would have been afforded the opportunity to submit a modified Review in Lieu of (RILO for the non-duty related DES case.  She could have requested to be placed on medical hold and extended her retirement date during the DES process. 

To request an LOD, members must be in a qualified duty status when they incurred/service aggravated an injury, illness or disease in accordance with AFI 36-2910.  However, members have up to 180 days after the end of orders to report any medical conditions that should be investigated for a LOD determination.  The member may contact the VA to receive medical care for any service-connected conditions. 

The complete advisory opinion is at Exhibit C.

The AFBCMR Medical Advisor recommends denying the application indicating the evidence presented is insufficient to warrant the desired change of the record.  The available medical record reflects the applicant received episodic care for acute injuries to her wrist, back, neck, feet and illnesses throughout her military service, none of which would have triggered a reasonably minded primary care physician to search for an occult hematologic malignancy via bone marrow or lymph node biopsy.  The medical note dated 5 May 19 stating there was increasing lymphadenopathy and splenomegaly X for several years is inconsistent with the available service treatment records.  Although there was evidence of gastrointestinal complaints consisting of diarrhea, dysphagia, neurological complaints, headaches, and dizziness, none of the specialty evaluations, which included MRI scans, CT angiography and comprehensive laboratory tests, identified a condition suspicious for an occult malignancy.

The treating oncologist stated the applicant’s migraines, swollen lymph nodes, upper and lower extremity weakness, rashes, vision complications and fatigue were diagnostic of Hodgkin’s lymphoma.  However, there are other symptoms more characteristic of suspected malignancy such as the onset of so-called B-symptoms, which include fever, chills, night sweats or unexplained weight loss.  Additionally, unremitting itching without obvious skin pathology can be an early clue to occult Hodgkin’s lymphoma.  Absent these findings, there was insufficient evidence to trigger a medical hold for malignancy.  The applicant was treated for basal skin carcinoma; however, the clinical record does not disclose complaints of rash or treatment of a rash, nor were there any instances of night sweats reported in the service treatment record at or about the time of the applicant’s release from extended active duty in Aug 16.

While the applicant contends medical providers did not conduct certain examinations or order certain laboratory tests, the treatment record reflects an earnest effort to evaluate and treat all of the applicant’s clinical presentations.  The applicant was found near universally worldwide qualified or was temporarily restricted from certain activities for over a decade.  Other than the applicant’s history of basal cell carcinoma and an abnormal pap, the Web Based Periodic Health Assessments failed to identify evidence of a potential internal malignancy or to prompt a search for a malignancy.  

There has been no evidence presented to assess if the military department failed to protect her from undue radiology risks.  Persons who perform duties near x-ray emissions such as dental professional or radiologists must wear a device that maintains a record of radiographic exposure levels.  Once the levels reach a certain level, it is generally advised the individual avoid exposure for a given time.  The applicant has not provided data from her thermoluminescent badge for a review to determine if she was exposed beyond accepted safety standards.  

The applicant’s history of flight line exposure to benzene-containing JP-8 fuel and deployments to regions where burn pits were in use, and her occupational exposure to radiation in the performance of her dental duties is acknowledged.  Again, the absence of a threshold dose for cancer initiation makes it difficult to identify as the root cause of occupational cancer.  Moreover, the association between cancer and radiation exposure in the workplace has not been clearly established due to lack of scientific evidence.  

The complete advisory opinion is at Exhibit D.

APPLICANT’S REVIEW OF AIR FORCE EVALUATION

The Board sent a copy of the advisory opinion to the applicant on 30 Mar 21 for comment (Exhibit D), but has received no response.

FINDINGS AND CONCLUSION

1.  The application was timely filed.

2.  The applicant exhausted all available non-judicial relief before applying to the Board.

3.  After reviewing all Exhibits, the Board concludes the applicant is not the victim of an error or injustice.  The Board concurs with the rationale and recommendation of NGB/SGPS and the AFBCMR Medical Advisor and finds a preponderance of the evidence does not substantiate the applicant’s contentions.  The Board considered the letter from the Recovery Care Coordinator and the implicit contention that the applicant’s Hodgkin’s Lymphoma was the result of environmental exposures during the periodic assignment of flight line duties in proximity to benzene-containing jet fuels, a 6-month long assignment near burn pits, while on EAD [2002 to 2004], and/or later due to exposure to ionizing radiation as a Dental Assistant [2014].  Despite the aforementioned petition, the applicant was consistently cleared to reenlist, beginning with a Palace Chase transfer in CY10, and consistently cleared thereafter for reenlistment up to her date of retirement. While an oncologist has reportedly characterized the applicant’s symptoms as indicative of Hodgkin’s Lymphoma, the supplied evidence shows the applicant was near consistently maintained on worldwide qualification status, with only temporary duty profile restrictions imposed, thus, not triggering a MEB or an LOD Determination. 

The Board also considered the applicant’s contention that had certain examinations been conducted during her service, she would have been diagnosed sooner and undergone a MEB. However, while the applicant has supplied ample evidence from the VA and the University of Tennessee, regarding her diagnosis, the Board did not find evidence that this medical information was provided to military healthcare providers for consideration of a Medical Hold, LOD Determination, or other action prior to the applicant’s retirement.   Therefore, the Board recommends against correcting the applicant’s records.  

RECOMMENDATION

The Board recommends informing the applicant the evidence did not demonstrate material error or injustice, and the Board will reconsider the application only upon receipt of relevant evidence not already presented.

CERTIFICATION

The following quorum of the Board, as defined in Air Force Instruction (AFI) 36-2603, Air Force Board for Correction of Military Records (AFBCMR), paragraph 1.5, considered Docket Number BC-2020-01563 in Executive Session on 3 Dec 20 and 15 Dec 21:

, Panel Chair
, Panel Member
, Panel Member

All members voted against correcting the record.  The panel considered the following:

Exhibit A:	Application, DD Form 149, w/atchs, dated 20 Jan 20.
Exhibit B:	Documentary evidence, including relevant excerpts from official records.
Exhibit C:	Advisory Opinion, NGB/SGPS, w/atchs, dated 3 Mar 21.
Exhibit D: Advisory Opinion, BCMR Medical Advisor, dated 17 Mar 21.
Exhibit E:	Notification of Advisory, SAF/MRBC to applicant, dated 30 Mar 21.

Taken together with all Exhibits, this document constitutes the true and complete Record of Proceedings, as required by AFI 36-2603, paragraph 4.11.9.