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Blog Talk Radio.

J Basser: 0:04

It's time for the Exposed Vet Radio Show. The Exposed Vet Radio Show, we discuss issues affecting today's veteran. Now here's your host, john and Ray. Welcome, ladies and gentlemen, to another episode of the Exposed Vet Podcast. Today is April the 11th 2022. Hope everybody's doing good. Got my co-host today, mr Ray Cobb, out of Tennessee. How you doing, ray?

Ray Cobb: 0:31

I'm doing great. How are you today? Kind of rainy and overcast, but it's a good day. Good day Got a lot done.

J Basser: 0:40

Been in duck weather here all day, too Off and on rain Ugly, but it's been warm. It's been duck weather here all day, too Off and on rain. It's ugly, but it's pretty warm. Guys, we've got a treat tonight. We've got the one and only Bethany Spangenberg, who is a valet I guess she is a valet. It's our company and we've been doing a series of shows basically covering some DBQs that the VA's got out there and for disability claims. And today we're going to discuss piping system, which the piping system is your vessels and your veins. And Betsy, how are you doing today?

Bethanie Spangenberg: 1:11

I am doing well and I'm excited because we have gotten our last frost, which means I can put my plants out, so I'm ecstatic.

J Basser: 1:24

I guess that's a good thing. Now, if you've got a green thumb, then you've got to be careful because it's stained.

Bethanie Spangenberg: 1:31

everything you've got, I always make the joke that we lived in Arizona for about five years and I could not for the life of me grow a tomato larger than a golf ball. And there is tomatoes Garden tomatoes are absolutely wonderful, Like if you go to the store. Those things have no flavor. You get one out of the garden. It's phenomenal. So tomatoes have always been something that I want to grow.

Bethanie Spangenberg: 1:57

And I've had more success in Ohio than I have in Arizona. So I always laugh about tomatoes because I could not get anything bigger than a golf ball out in Arizona. That heat just killed the tomatoes.

J Basser: 2:09

And the soil doesn't have nutrients too. You know it's different. A lot more sand and stuff out there. So yeah, ohio, you've got some good nutrients in the soil to do that stuff. So that's what makes the big, you know, the big boys and the good tomatoes.

Bethanie Spangenberg: 2:26

Well have you ever tried the German?

Ray Cobb: 2:29

pink tomato? No, I haven't. It's a much larger tomato. They're a little harder to find, but the German pink is really a good juicy. It's almost like a softball.

J Basser: 2:44

So they're really good. Another reason they don't go so good, I tell you there's not a lot of honeybees. You know you got a bunch of honeybees in Ohio. That makes a big difference.

Ray Cobb: 2:53

Yeah, it does when those things are blooming.

J Basser: 2:56

If it wasn't for a honeybee, we'd all be dead.

Ray Cobb: 3:01

Yeah.

J Basser: 3:03

I'm serious. It's all late, of course, course not. I wish they could tap you and make you feel better and make you health better, but they can make you eat better. Yeah, no, let's get on to see. Are the reasons? The DVQ probably a very long, isn't it? It?

Bethanie Spangenberg: 3:27

is, and I've actually, you know, I took that into consideration for the time that we have for the show and you know my notes are a little bit longer than what I think we'll actually get through, but you know, I've got a pretty extensive series of topics for today in this DBQ.

J Basser: 3:46

Okay, go right ahead and get started on it. All right.

Bethanie Spangenberg: 3:59

So, as usual, I have the DBQ in front of me. This DBQ is seven pages. As usual, I have the DBQ in front of me. This DBQ is seven pages. It is the Artery and Vein Conditions Vascular Diseases, including Varicose Veins, dbq. So, as usual, the first page is the name, the provider, like what role they play if they're a VA health care provider. They ask if the veteran is a patient in the clinic and then it looks at.

Bethanie Spangenberg: 4:32

The next section asks about what evidence was reviewed, and it's always important to make sure that evidence is there for that examiner to review. For this particular DBQ, things that are important are any type of treatment records for your vascular condition, any type of vascular testing that can be done, and your vascular testing isn't like an x-ray. It's typically more involved and you'll be aware of when those tests are done. So what's also unique to this DBQ, I guess, as compared to the other ones that we've done so far, is to ask about the dominant hand. So the dominant hand is important because if the vascular condition affects a dominant extremity, like a dominant hand, you can get a higher disability rating if it's your dominant hand that's affected. Dominant hand that's affected.

Bethanie Spangenberg: 5:32

So section one has the examiner outline the diagnosis, and the list of diagnosis that we're going to talk about today are the varicose veins, the post-phlebitic syndrome. Today we call that post-thr syndrome. So when you actually like go to try and find post phlebitic syndrome, you're really just going to pull up va regulations. You're not going to find a lot of medical material for that because it's an outdated term. So if you're going to try to find information on it, you want to google post thrombotic syndrome. The next one we're going to talk about in this list is Raynaud's disease. Raynaud's syndrome. On page two the list of diagnoses keep going. It's thromboangitis obliterans, also known as Berger's disease. I'll briefly discuss arteriovenous or AV fistulas and then we'll talk about peripheral artery disease. The next section, section two, is the medical history. It's a very brief statement there for the medical examiner to document a little bit of the vascular history.

Bethanie Spangenberg: 6:44

So our first big section is going to be section three, and so section three is going to look at varicose veins and or the post-phlebitic syndrome. So again, the post-phlebitic. I'm going to use it interchangeably with post-thrombotic. I'm not trying to throw you off, it's just again, that term is old. So using today's medicine it's a little bit. You know you have to mindfully think about what you're saying, but so post-thrombotic syndrome occurs after a DVT or a deep vein thrombosis.

Bethanie Spangenberg: 7:20

You get a blood clot in the leg and the damage that is done is called post-thrombotic syndrome. Most often they occur in the lower extremities. Most people have heard of somebody who's had a DVT or a blood clot in the leg. Some veterans have undergone an ultrasound in an extremity for a blood clot in their lifetime At least I know that we've ordered quite a few when I was in the clinic. A blood clot in their lifetime. At least I know that we've ordered quite a few when I was in the clinic. Hopefully, john Ray, you guys haven't had to experience one of those, because they can be pretty scary. Have you guys had to have an ultrasound done? Have you guys had to have a DVT ever?

J Basser: 8:09

Have you guys had a DVT ever? I've had all the testing done for the stuff. I've had all the ultrasounds and all the vascular tests, but never had a DVT.

Bethanie Spangenberg: 8:23

But I've got Renaud and some other stuff going on. That's good. So the DVT test is an ultrasound. It's nothing invasive, it's about a half an hour test. By the time they get your dress set up in the room it's usually pretty, not too long.

J Basser: 8:39

They did one on me a couple years ago and it didn't really show anything. But my provider said no, you put them on a treadmill and do it, and then they put it at two degrees on an elevation and if your legs get tired within so many feet, that's quadulation. So that's one of the things I write it to in the rating schedule for that. For the standing up one you ever seen that test?

Bethanie Spangenberg: 9:03

I have not. What do they call it?

J Basser: 9:06

It's the same type, it's the same vascular test, but instead of laying down, say, for example, if you've got Raynaud's, you know your feet will turn purple if your feet are down. But if they raise your feet up to do the ultrasound, then the elevation will give bad readings because it won't show, because basically it's your arteries, arterial pressures. But if they put you on a treadmill they can measure it better because you're actually moving and they can measure how long it takes your legs to get tired and that's how they do venous infancy.

Bethanie Spangenberg: 9:41

You know, I'm glad that you brought that up because I forgot Like. I know that we've talked about you having Raynaud's before, but I didn't put two and two together about you having all these additional vascular tests for that condition, because normally when you have Raynaud's. They do a full workup to see what else is going on oh they don't touch it.

J Basser: 10:01

They try to. My VA is different than theirs. They try to shy away from stuff. So it's kind of a catch-22. We put them in, you know Okay.

Bethanie Spangenberg: 10:15

So for Section 3, this is looking at vein conditions. I know the test you talked about also looks at arteries and actually arteries are in Section 4, so we'll talk about that. So 3A asks about varicose veins and it wants the examiner to identify if it's the upper or lower and which one is affected. Question 3B is asking about that post-phlebitic syndrome.

Bethanie Spangenberg: 10:43

They're just trying to identify what you're documenting in the exam and the history portion. So for question 3C, the examiner is to look and see if there are varicose veins and if they're asymptomatic, they're to document where they're located and if they're able to push or feel on them. Some people experience aching and fatigue in the legs with varicose veins after prolonged standing or prolonged walking, and so they have to identify. The examiner has to identify if you have those symptoms as well. One question on here asks about if symptoms are relieved by elevation of the affected extremity or if the symptoms are relieved by compression hose. And normally with your vein conditions, the compression hose is going to be your standard treatment initially. And then the last one is if someone has a vein issue, are they having constant pain at rest? So those are the main symptoms that the examiner will identify, but the individual veteran may actually experience more symptoms than just that. So it's important that in your statement of the support acclaim you want to make sure that you document all of your symptoms, even though that examiner may only ask you about specific ones. They are targeting what is in that DBQ. So if we look at question 3D, this is the actual examination portion, when the examiner looks to see if there's any discoloration. That is known as stasis pigmentation, Sometimes it's called bronzing. That's where the blood or the fluid pools in the legs and over time it creates discoloration. It's like a brown color.

Bethanie Spangenberg: 12:37

They're also supposed to look for eczema or where the skin is irritated from the pressure, from the fluid. They're supposed to inspect for swelling, if that swelling is intermittent or persistent. And then the other few things are typically present when there is more advanced disease. So they're supposed to look for ulcerations or sores. They're supposed to document if you have a history of the ulcerations or sores. They also are to look for where the skin starts to harden. So they push on the skin and it's actually hard because of the swelling within the skin.

Bethanie Spangenberg: 13:23

And then the last one is the massive board-like edema, and I quote massive board-like edema because that is what is in the DBQ. That is not a common term that we use in the clinic, but what that means is that the swelling is so advanced, it affects both the lower portion of the leg and the upper portion of the leg and it literally looks like one straight board. So we haven't seen, or I haven't seen, a lot of the board-like edema. Normally it's when the individual has a more advanced disease. Before we see something like that.

J Basser: 14:02

So that's really it about Pardon. You want a picture of me.

Bethanie Spangenberg: 14:11

I'm going to pull it right up.

J Basser: 14:19

So while we're in, this section.

Bethanie Spangenberg: 14:21

While we're in this section, I do want to touch about Go over the actual rating schedule when it comes for those vein conditions. So a veteran will receive a 0% if the varicose veins can be seen or felt but are asymptomatic. A veteran may receive 10% if they have intermittent swelling of the extremity or aching and fatigue in the leg after prolonged standing or walking and the symptoms are relieved by elevation or compression hose. So that's what the predominant one we see is the 10% rating. The 20% rating is if the veteran has persistent swelling and is not relieved by elevation, and the veteran may or may not have beginning discoloration and skin changes. A veteran may receive 40% if they have persistent swelling and the discoloration or the skin change with the eczema with or without intermittent ulceration. A veteran may receive 60% if they have persistent swelling, their skin is starting to harden, the skin is discolored or they start to see the sores or the irritation. They start to see the sores or the irritation and they have persistent ulcerations.

J Basser: 15:47

You don't want to hit 60%.

Bethanie Spangenberg: 15:48

So even 40% you're in trouble. So 40%, 60%, 100% even you can get. Those are things that are more advanced disease. So a veteran may receive 100% if they are in constant pain because of massive board bored like edema even while at rest. So those are big ones.

J Basser: 16:11

Can you elaborate a little bit on the actual? You're talking about the skin. The skin changes. Yeah, like the hair disappears and it gets real shiny and things like that. I'm sorry I couldn't hear you very well. You know, when your skin gets to where like, for example, you lose all your hair down the legs and your skin turns real shiny turns real shiny.

Bethanie Spangenberg: 16:49

So we see a lot more skin changes with arterial blood diseases than we do for vein diseases Because, if you think about it, the arteries are what supplies the oxygen. So we're starting. You know they're still getting if there's no artery disease, they're still getting the oxygen to the body. Whenever the veins are affected, normally we don't see as many changes. As the disease progresses is when we start to see that change because all the pressure starts to create troubles with both directions.

Bethanie Spangenberg: 17:19

So the one thing I should also talk about is your arteries are really propelled by the pumping of the heart, so there's a little bit of muscle structure fibers within the arteries themselves and so the heart is pushing that blood through the body.

Bethanie Spangenberg: 17:39

Now your veins, they actually have little cups or little valves that help to push everything back up to the heart through the lungs for it to be recycled.

Bethanie Spangenberg: 17:50

So, even though they have different functions, when you have pressure in the lower extremities, whether it's from the artery disease or whether it's from vein disease, they start to affect each other Again confined compartment and then you get the swelling from even heart failure.

Bethanie Spangenberg: 18:10

When you get the fluid overload it can start to create dysfunction within those vessels in the lower extremities. So predominantly, when we look at the vein dysfunction, we're seeing more of the bronzing and what we call pitting edema. And your providers have probably done it if you're over 40, to be honest because our providers are taught that some of the first signs of heart failure can be seen and appreciated in the lower extremities. So they'll look at your bone in the lower extremity and they'll push on you and they'll talk about what we call pitting edema and they grade the pitting edema on how well that edema goes back, like it goes back to normal. So the bronzing is the predominant skin change that we see in the vein dysfunction as it progresses. That's where we start to see the eczema, the ulceration, the hair loss, the shiny skin, the skin breakdown.

J Basser: 19:18

What do they call it when the valve stops working?

Bethanie Spangenberg: 19:21

Venous insufficiency.

J Basser: 19:24

Really you think that's attributed to hypertension, or is it something else? Um that means maybe so Venus insufficiency?

Bethanie Spangenberg: 19:39

gosh, there's so many components. It's almost one of those things like, like diabetes diabetes causes so much stuff that even the venous insufficiency has so many contributing factors. Even obesity can cause venous insufficiency because the pressure from the belly sits on the legs and it creates more work for those veins to get back up through to the heart. So a lot of venous insufficiency that we see in our heavy people it's because their belly sits on their legs and causes more pressure and so those valves are not you know. They're working twice as hard to get the blood back and they're just not able to keep up working twice as hard to get the blood back and they're just not able to keep up.

Bethanie Spangenberg: 20:27

I, you know I'm not. I will have to look directly to see if hypertension is a risk factor for venous insufficiency. I know that if you look at it from a population base, there probably is a a relationship there. But I know that the arterial disease and hypertension have a relationship, and that's the next section that we're going to dive in is the arteries good deal any other questions about the veins or varicose veins or?

J Basser: 21:04

Like I said, the last time you've done any DDQs, you must have had me in mind.

Bethanie Spangenberg: 21:12

I did write down some information regarding the history and risk factors for the varicose veins, and where did I put it? Because the varicose veins have a predominant genetic component as well, but there is contributing factors and I can't find where I put it. Maybe I'll find it later down. Let me see Genetic, okay. Okay, all I put is their significant genetic component in developing varicose veins as well.

Bethanie Spangenberg: 21:54

So whenever the examiner goes and sits down and they have to write a medical opinion about your varicose veins, they are going to consider the genetic history as well. But there's so many other things, like we talked about, for the obesity that can contribute. If you have a DVT or an injury to the lower extremity that can develop varicose veins, trauma, compartment syndromes where they have to go in and cut people open to release the fascia on the lower extremity. So, moving on to section four, at the bottom of page two, question 4A is asking if the veteran has ever been diagnosed with peripheral arterial disease or thromboangitis obliterans, and that's Berger's disease that I was talking about. So Berger's disease is associated with smoking and because we've seen a reduction in smoking, we're not really seeing this Berger's disease appear as predominantly. But what happens is it affects the smaller blood vessels and inflammation occurs in the smaller blood vessels and it causes the arteries to not work. So it blocks the blood flow going to that particular area of the body. We actually see these in the upper extremities more commonly or in like the digits or the feet, digits or the feet, and you can actually lose the digit, the finger, or you can lose, you know, that part of the skin can die off and you can get sick from that dying tissue. So not very common. I've never seen it in the clinic. I'm aware of the condition because we have to look for it. The numbers for that condition have gone down so there's not really a lot of value for me to kind of dance over that a whole lot.

Bethanie Spangenberg: 24:00

Section or question 4B asks about any types of surgery for the artery disease. Section 4C is asking about any other surgeries or procedures for revascularization and question 4D is symptoms and the symptom questions. For 4D is only looking at Berger's disease. It has nothing to do with peripheral arterial disease. Peripheral arterial disease in the rating schedule is driven by tests and the numbers that are actually involved with the testing. So I don't know if you guys have heard of an ABI or an ankle brachial index, but that is what tests the pressure in the arteries themselves. And this might be something that they had to do with that walking and where they're trying to see how those arteries respond.

Bethanie Spangenberg: 24:58

So in the clinic if I do an examination and I notice some physical examination changes on the veteran, I can ask the nurse or the LPN to do an ABI in the clinic. So the ABI only takes about 10 minutes to do. The LPN or the nurse can set up the blood pressure cuffs on the legs and get the pressure points at each of it. So it's more of a screening tool than it is anything. But I really appreciated that in the clinic because a lot of the veterans that I was seeing they had all these risk factors for peripheral arterial disease but nobody had really looked at their legs.

Bethanie Spangenberg: 25:46

So I always had my veterans take their socks and shoes off. I want to see their ankles, I want to see you know what's going on below their knee, because that's where we can see early signs of heart failure, where we see early signs of artery disease or vein disease or even infections in the toenails or issues with the feet. You see a lot when you look at an individual from their knees down and so I would always have my veterans take off their socks and shoes and roll their pant legs up so that I could see that. So with our artery diseases, as those arteries start to dysfunction, you're not getting the oxygen to that tissue. So you start to get like a blue hue to the skin, maybe a little bit of a green tint to the skin it's not pink and bright. A little bit of a green tint to the skin, it's not pink and bright. Then the skin will start to like you don't have as much fat then you, you don't have the hair, you don't have the fat, the muscle structure starts to get thin.

Bethanie Spangenberg: 26:48

So they have these really thin legs when you have just the artery disease component.

Bethanie Spangenberg: 26:55

And so some of those visual signs are like oh, I'm concerned that they may have peripheral arterial disease. So, if you're listening, take off your socks and shoes, look down at your feet. If you see any blue or greenish discoloration, if you see loss of hair, if you notice that your legs are a little thin they're not as muscular as they used to be, and you can even push your fingers over your big toe, between your big toe and your little toe, just to meet below that and start to feel for your pulse. Those pulses should be. You should be able to feel those pulses readily. And so all those things are signs of arterial disease. And by using an ABI or getting an ABI, that's a screening tool to let the veteran know what is going on with their legs. And so if you're concerned, certainly ask about, ask your primary care provider's not invasive, it's an a good screening tool, and that way you can be aware of what's going on with your arteries, some of those treadmill tests that you were talking about those are typically done in the primary care.

Bethanie Spangenberg: 28:11

That's normally done through a specialist.

J Basser: 28:14

Yeah, something to the ultrasound. Yeah, usually radiology specialists in the ultrasound. You can do that in the hospital setting and they'll do it. They'll do the testing Some people in production. They'll do other tests. They'll do a catheter refill test on you and basically look at it and take the pressure on your press and they see how long it takes for the color to change back from white to pink or purple or whatever you get.

Bethanie Spangenberg: 28:44

Yes.

J Basser: 28:45

And I guess they count it by so many seconds or whatever and that kind of tells them to go ahead and do the next test or whatever, because it takes over so many seconds and the other issues. Yeah.

Bethanie Spangenberg: 28:59

You know I have had, so I've had some, I guess, when I look at chronic disease. I've done geriatrics, I've done dementia care, so a lot of my experience is with the older individual and so appreciating those changes associated with arterial disease is something that I'm used to seeing and I'm comfortable looking at and examining. But sometimes you know, patients don't really appreciate those changes in themselves and they come in complaining about cramping in their calves.

Bethanie Spangenberg: 29:29

And when an individual complains about cramping in your calves, as the clinician they have to decide okay, is this a nerve condition that is irritating your calf because you have a back problem, or is this a vascular issue where you're not getting the blood supply to the muscle and it's starting to cause pain in the calf and we call that claudication when it's associated with walking or cramping in that calf muscle? So I think for this DBQ, the peripheral arterial disease is the predominant one to really take away, because we see that more common in your diabetes, in those with hypertension, in those with chronic kidney disease. They say that 10% of adults over the age of 55 have some type of peripheral arterial disease and if you throw on some of those chronic illnesses, that's going to play a part in the development of arterial disease as well.

J Basser: 30:33

That's the basis illnesses that's going to play a part in the development of arterial disease as well. Yep, that's the basic. Makes it worse.

Bethanie Spangenberg: 30:41

Yes, so I'm not going to break down 4D as about the symptoms of Berger's disease, because that section has nothing to do with peripheral arterial disease, just particularly Berger's disease, and we don't see that very often.

J Basser: 30:55

I've never seen it.

Bethanie Spangenberg: 30:59

Pardon.

J Basser: 31:00

I've never seen it. Yeah, section 5.

Bethanie Spangenberg: 31:09

For time purposes I'm going to skip over Section 5, 6, 7. Those are looking at aneurysms and aneurysms they. When we hear about aneurysms it's either from a couple of places, as we know somebody who's had a brain aneurysm that ruptured suddenly and they died. Usually those are your younger individuals. They didn't know they had it. It's something that just happened developmentally. There's not a lot of like brain aneurysms that occur as a result of some other disease. They're not predominant in that manner. The other place we hear about aneurysms is if you have certain risk factors. The VA computer system, the medical charting system, flags an individual who has risk factors for an abdominal aneurysm. So if you have, like a certain pack here history, or you've been diabetic or you have, you know, other concerns or diagnosis in your chart, the charting system will actually tell that clinician. Hey, this person qualifies for a once-in-a-lifetime screening of their abdomen to see if they have an aneurysm.

Bethanie Spangenberg: 32:24

And so they've been really pushing that abdominal ultrasound to see if you have an aneurysm. Have either of you had one of those done Normally they're pretty common.

Ray Cobb: 32:37

Yeah, I've had one done when they were looking for a ruptured appendix and they found it and I went to surgery. Oh, wow, kind of interesting what they were able to see. At first they didn't think I had one, and then I had the stomach pain, stomach cramps and everything. And then, when they did the ultrasound on the stomach, they first thought I might be having an ulcer, and then, as they got lower, they first thought I might be having an ulcer, and then, as they got lower, they saw my appendix had not only ruptured but a protective bag had surrounded it to protect the infection from spreading through my body. And it had been that way, they think, for four or five months.

J Basser: 33:35

Oh my.

Ray Cobb: 33:36

Once they got in there and removed it and everything, and I had experienced, you know, paying for a day or two and go away for four or five and then have the pain again for another day and go away, you know, over a three or four month period of time, and they told me at the time that that was not unusual for athletes, especially swimmers. Now, I wasn't a swimmer, but, they pointed out, especially for swimmers.

J Basser: 34:12

You swam, you were a water skier. Right, you had to do it, man.

Ray Cobb: 34:16

I had to tread a lot of water right, you had to walk on water.

Bethanie Spangenberg: 34:22

I wonder why that is. I'm going to have to look into that. You have me real like my head scratching. What is it about swimming that would cause you to be more at risk for those, I don't know? Well, the chlorine that would cause you to be more at risk for those I don't know it could be Well, the chlorine I mean.

Ray Cobb: 34:38

you know, most swimmers are actually in chlorine, not in a lake like I was skiing you know every day for so many years.

J Basser: 34:50

Huh, you know you were talking about triple abdominal. I've had a couple of tests though, but it's usually one of those conditions. If you've got uncontrolled high blood pressure, then I think it puts you on the list anyway.

Bethanie Spangenberg: 35:02

Yeah, it does.

J Basser: 35:07

I'll probably get another one here in a couple of months anyway.

Bethanie Spangenberg: 35:11

Normally what happens is they kind of like if they find like a weakening or a break in the wall, which is what an aneurysm is in that vasculature, there's a weakening in the wall they always talk about, like the garden hose being like a double layer, and so it's part of the layering has torn or it's weak, and so they would go in and support the garden hose with a cage or mesh or some type of structure to kind of keep everything together.

J Basser: 35:43

Some type of Gore-Tex. Yeah, you have to use that for my wife one of the days. She used to do that the rest of her life. Yeah, she really enjoyed her bird and putty job used to do. That's the last of their lives. Yeah, yeah, you really enjoy that. But plenty.

Bethanie Spangenberg: 36:02

So for section eight, this is Raynaud's disease or Raynaud's syndrome. Is this something, john, you want to kind of talk about the disease itself?

J Basser: 36:12

Raynaud's is a condition to where, uh, your capillaries and small blood vessels in your feet and toes doesn't get enough oxygen and it's basically because of a cold-natured environment. If your feet get cold and you're in a cold area, you don't have your feet warm and protected, you have them down. What's going to happen is your feet are going to turn a bright purple color. Your toes are going to sag. You can push on your foot and you can watch. They start to ache and they can cause open sores and amputation. There are two types of Raynaud's. You've got primary Raynaud's or secondary Raynaud's. Primary Raynaud's, basically, is a primary condition. You know. It's not secondary Raynaud's, caused by another condition. Now there's still a lot of research on this going on, because they're trying to figure out what the causes are for secondary Raynaud's and they're trying to skate away from the diabetes factor, because they used to call Raynaud's diabetic disease. But I don't know how they're doing. They're denying a lot of claims now for it. So what's your take on it, bethany?

Bethanie Spangenberg: 37:15

So, as far as when it comes to the DBQ itself, the VA, or whoever created the DBQ, tries to differentiate between Raynaud's disease and Raynaud's syndrome, and I don't from a clinical perspective I cannot appreciate the difference in their definition. So your Raynaud's disease is going to be your primary, like you said, your Raynaud's syndrome is the secondary, and so in the clinic we kind of use all those terms interchangeably, including Raynaud's phenomenon.

Bethanie Spangenberg: 37:51

But you're right, the primary Raynaud's is when it occurs without cause, like we don't know what's going on.

Bethanie Spangenberg: 37:59

It's like a primary issue and normally those are seen in your younger individuals, 30 and under, and then the secondary Raynaud's is. My understanding from the clinical side of things is that the nerve, that it's a vascular response that is affecting the nerve, whether it's the blood supply, whether it's compression, whatever it is, both cold temperatures and even emotional stress can cause those changes in the skin colors and can cause numbness and tingling and pain as they go through all these color changes. And I've the primary raynaud's, the color changes that I have appreciated are much, um, they're more striking visually. So you get a deep, deep blue and a very bright, bright red and a white, where in the secondary Raynaud I tend to see like a dollar component is not as bright. So I don't know if there's a difference or why that is. I don't know if it has to do with, like the blood supply and you know, having those underlying diseases. But that's one thing that I've appreciated clinically is that there is a little bit of a difference in the actual hues of the colors.

Ray Cobb: 39:21

Bethany, talking about the colors, I have a question. My sometimes the toe next to my big toe will turn the dark blue, like you're talking about, for a day or two that's right will turn the dark blue like you're talking about for a day or two Right now. Okay, Now my diabetic doctor says it's because of diabetic neuropathy. Is that correct or incorrect, or?

Bethanie Spangenberg: 39:46

should we look further about that? I would be concerned primarily with the vascular issue. If you have not had workup for peripheral arterial disease, that would be where I would start. Yes, diabetic neuropathy can cause some reaction of the blood vessels. But if you have not had the workup for peripheral arterial disease, that would be where I'd start, because with being diabetic and if you have the arterial disease and it's in your toes, you're at risk of losing those toes and those digits.

J Basser: 40:20

So you definitely want to make sure that it's investigated in the meantime where you can actually once you see it like that you can actually go ahead and get Pam to help you get out with that leg straight, get it up a little bit, see if that goes away. If it goes away, then you might have brain nods. If it doesn't, you've probably got a different issue.

Ray Cobb: 40:40

Yeah, we do that. Matter of fact, we actually purchased a bed that I can lay down on and raise the feet like a hospital bed for that very purpose. And sometimes I'm wondering, I'm trying to figure out the difference when they tell me I have severe neuropathy and I cannot feel them stick a pin in my foot or a needle, but I do have that tingling sensation. You know, really tingling, kind of burning.

J Basser: 41:15

Now I have had pardon, Pardon burning or stinging.

Ray Cobb: 41:21

Kind of stinging, I guess, like a little bee sting or a bunch of ants biting you.

J Basser: 41:27

And.

Ray Cobb: 41:29

I have actually. They have put the pressure cups on my lower leg and checked me all out that way and tell me everything's normal. So they, you know, kind of drop it. I've had that done twice, so I don't know. It just doesn't happen very often probably twice, three times a year It'll turn dark blue and a day or so later it's back to normal.

J Basser: 42:00

I can touch on the testing part for Raynaud's. There's a lot of mistakes made in Raynaud's Bethany for testing Because these ultrasound techs, you know they get in and they're doing the blood gas studies and ABI's and this stuff. They put the monitor cuffs on your feet and toes and do their stuff. But in order to test for Raynaud's you've got to be in the actual situation. If your feet are elevated, then the blood flow is going to help out, it's going to improve. It's got to be tested in this natural condition and they've got to raise you up and let your feet hang down. Do you know that?

Ray Cobb: 42:35

No, but they never did that with me. I mean, I was always laying down flat, you know, when they did the test on me.

J Basser: 42:42

Yeah, so it's laying down flat. You know, when they did the test on me yeah, that's got to be the acupuncture.

Bethanie Spangenberg: 42:46

Yeah, I was not aware of all the special testing for Raynaud.

J Basser: 42:50

Mm-hmm, it's got to be an accident because, basically, Raynaud only affects your feet when they're down and the reason it is is, say, if you're standing or if you're shaking your feet down on the ground, it's because the throat is pointing from your heart to where your blood flows down below. And if it's all the way down and your feet are cold enough and it can be anywhere, it don't have to be super cold. Your feet can stay cold. You know, some people have to wear thick socks to bed. Yeah.

J Basser: 43:19

You know, but you can also have Raynaud's in your hands and feet, and I'll tell you something else. You look, but you can also have Raynaud's in your hands and feet, and I'll tell you something else. You look at your nails in your hands and your feet and if you see lines going from the nail bed toward the front of your toe, a bunch of them on each nail, then you've probably got Raynaud's. Yep.

Bethanie Spangenberg: 43:46

So, when it comes to the DBQ, question 8A and 8B are asking for the examiner to differentiate between primary and secondary.

Bethanie Spangenberg: 44:00

Question 8C asks about the characteristics of the attacks, like how frequently and do they occur, with some of your skin changes, some of the skin changes we've talked about a little bit, but some chronic skin changes that we can see with Raynaud the thinning of the skin, the skin cracks, the ulcers and then the changes in the nail, the nail shape and texture, and then HE, which is interesting, and I've never seen this in a Raynaud's component. But they ask about auto-amputation. Has the veteran or have they had auto-putation of one or more fingers or toes? And what that is is the body because the blood vessel, because of this blood vessel spasm and it's not getting oxygen, the finger or toe loses the blood supply and it falls off. So the body just automatically amputates itself. The digit falls off because it's not getting blood supply. I have never seen that, I've never heard of it related to Raynaud's. I have heard of it associated with diabetes and some of your chronic vascular issues with diabetes, but not in a.

Bethanie Spangenberg: 45:17

Raynaud's component. Let's hope that doesn't happen. For the rating schedule specifically just going to read that out it's based off of how frequent the attacks are.

Bethanie Spangenberg: 45:31

So, if the veteran experiences an attack one to three times per week. That's a 10% rating. A 20% rating is indicated. If the attacks occur four to six times per week 40% rating. If the attacks occur four to six times per week 40% rating. If the attacks occur daily and they're talking about the attacks, that's, the vascular spasm, the skin color change, the tingling, the pain, that type of issue. A 60% rating is indicated if the veteran has two or more ulcers, as well as the characteristic attacks. And then 100% rating is indicated if the veteran has two or more ulcers and auto-amputation of the digit with the attack. So I don't know if we're going to get to 100%. I don't want to see that issue.

J Basser: 46:22

Well, a lot of guys have it secondarily. Every time your feet get down, every time you put your feet down, it happens. So you know, I have myself. I have a secondary attack per week, two, three per day. Actually I haven't had any amputations, which is that's only because of nitrobed. You know what nitrobed is. Nitro, what nitrobed? You know what nitrobed is.

Bethanie Spangenberg: 46:45

Nitro what?

J Basser: 46:47

Nitrobed. It's a nitrolyserine cream you rub on your feet.

Ad: 46:51

Oh, I've never heard of that.

Ray Cobb: 46:52

Mm-hmm, yeah, and they rub it on your toes.

Ad: 46:56

Is that what they use for the?

J Basser: 46:56

radons yes.

Bethanie Spangenberg: 47:00

Oh See, you're teaching me something. Yeah, they gave that to me they can give another medication.

J Basser: 47:08

They can give you like a isosorbide, like a slow release nitro, like yeah basically it's a vasodilator opening up your blood vessels.

Bethanie Spangenberg: 47:18

So it can help. I'm aware of that for, like cardiovascular issues, I've never heard of that for Raynaud's.

J Basser: 47:25

It's still a vascular issue. I mean it's still capillary, it's still, you know, small blood vessels, but it still works. And since they're close to the skin then the natural blood works better because you know it's closer to the actual point. You know, but anything to keep us. You know we like to walk into IHOP. You know we don't want to have to hop into IHOP.

Ray Cobb: 47:51

Well, I've already been hopping for a long time into IHOP.

J Basser: 47:55

Been hobbling down.

Ray Cobb: 47:57

Yeah, yeah.

Bethanie Spangenberg: 48:02

All right, we're almost through the majority of the DBQ, so I'm going to actually just power through and finish up the last few questions here traumatic component normally let me back up the typical time we hear about an AV fistula is if an individual is undergoing dialysis for kidney disease, and so they'll go in and have surgery and do an AV fistula in order for an individual to have dialysis for kidney failure. They can occur through trauma, but that is less common. Section 9, section 10 talks about tumors and neoplasms related to vascular diseases. The only reason I'm really touching base on this is a lot of the tumors and neoplasms or neoplasms is just another name for a tumor or a growth but a lot of the sections will have an area for tumors and neoplasms. So, for example, when we look at, like the bladder conditions TBQ, it will also ask about tumors and neoplasms. So they just want to know if, whatever that growth is, is it non-cancerous, is it cancerous and is it active? And that's the same that's going on in this section of the DBQ.

Bethanie Spangenberg: 49:35

Section 11 asks about amputation and assistive devices. If an individual has a mutation as a result of a vascular issue, that C&P examiner is to go on and do the dedicated DBQ for amputations. There is a DBQ for amputations and it is not contained within this DBQ, so that would be another examination. And then the next section is just an area for the examiner to write any other physical exam findings that they appreciate during the exam, and page seven, which I somehow lost. Where did my page seven go, oh my goodness. So give me a second so I can pull it up. I must have dropped it somewhere. I don't know where I lost it. Look at me. I said I was all prepared and I didn't. All right, I've got it now.

Bethanie Spangenberg: 50:49

So page seven of the DBQ talks about any diagnostic testing and this section is actually where that ABI pressures go in for the peripheral arterial disease, so that ABI testing doesn't go with where they should have put it. But it goes in this section and that's where you're going to look for your rating and you're going to compare your testing results in that section to the rating schedule in order for you to understand what your rating would be for peripheral arterial disease. And then the next section is functional impact. We see this in every DBQ. It's asking about any limitations or issues with occupation with your activities of daily living.

Bethanie Spangenberg: 51:42

Sometimes, if the examiner feels that the veteran's condition is not severe enough to cause a functional impact, sometimes they won't even talk to the veteran about it. So I always emphasize put it in your statement of support in support of your claim, so that way it's documented and in the record. And then the last two sections are for any additional remarks and the examiner's certification, their area of practice, their license number and things like that. So very heavy, lots of information in this DBQ. I think again, the primary takeaway for this is, or the predominant rating component in this is going to be, your peripheral arterial disease.

J Basser: 52:29

So any questions about the causes we're talking about. The fact right now is we're talking about some of the causes, and some of the causes that they're used at, that the professionals and some of the literature is showing is that the causes are basically some type of autoimmune like maybe rheumatoid arthritis might be a cause of Raynaud's or even pulmonary hypertension. So if you've got lung disease and poor young, that's something you can look at.

Bethanie Spangenberg: 53:01

You know, I've predominantly seen Raynaud's in autoimmune conditions and in scleroderma. Scleroderma is a very sad disease, but we see a lot of Raynaud's in scleroderma. So scleroderma is basically your skin and your tendons start to harden and scar and so you become immobile. It affects your internal organs and your tendons start to harden and scar and so you become immobile. It affects your internal organs.

J Basser: 53:29

And you can see where. Yeah, yeah, my wife's uncle had it. He had got it. He's getting on with it. We probably skin and tendons trashy today, right?

Bethanie Spangenberg: 53:51

yeah, usually they. The life span for somebody with scleroderma is normally like in their 50s, so they don't have a full long life, unfortunately. It's sad.

J Basser: 54:10

I don't mean to say it sucks too. They do so many of them. But if you've got a lung disease and you've got pulmonary hypertension or if you've got these issues, get them checked out and got it. Find somebody to look at it and get your diagnosis and get that in there, especially with brain nods and being a sense of efficiency. If you've got the vascular problems with the valve and stuff like that, that can be attributed to a lot of different things.

J Basser: 54:45

So you know, don't give up on it. If it's your benefit, go for it. Yeah, and.

Bethanie Spangenberg: 54:53

I just want to emphasize that. You know peripheral arterial disease is probably underdiagnosed because clinicians tend to not look at the feet of their patient. Even patients don't necessarily like to show their feet. Sometimes feet is a thing for some people. But yeah, if your clinician hasn't looked at your feet once per year, you need to get a pedicure done and show them your toenails because they need to be, looking at your remedies to see what's going on.

J Basser: 55:27

As a matter of fact, diabetic vets you know usually if you've got speed issues, podiatry is a really good one to do that. Podiatrists can also help you out a whole lot when it comes to speed, especially, you know vascular issues. They can order the test too, but I mean the podiatrist that's their main job.

Bethanie Spangenberg: 55:47

Right.

Ray Cobb: 55:52

Mine checks mine pretty thoroughly every six months.

J Basser: 55:56

There you go, what you need. And you can tell that the seriousness, the seriousness of your fetus, you by your recall time to va, if you go to va, if it's every three or four months or something going on you're correct, because that exactly happened to me.

Ray Cobb: 56:15

And uh, he said let me see you in about three or four weeks and uh know, well okay.

Ad: 56:24

Didn't say what was wrong or what?

J Basser: 56:26

had him puzzled, but he wanted to see me in three or four weeks. Same thing with my EP doc. I've got to go back every four months. Now I think I've been to the VA already over 40 times this year.

Bethanie Spangenberg: 56:41

It's just now April, I was going to say oh my goodness, yeah, oh, but my vehicle knows the way.

J Basser: 56:53

I just push the button and say go, I'd take a nap on the way. I'd take a nap on the way. Good job, bethany, as usual.

Bethanie Spangenberg: 57:09

Thank you, and actually we put out a couple of blog posts, particular, specific to the vascular issues, so you can look at some of that information we talked about and the rating references on our blog. And you and I talked briefly. I think the next DBQ we're going to tackle is going to be the scars and disfigurement DBQ. That's another big one.

J Basser: 57:36

That's been a big issue on one of the sites. I think too people talking about scars.

J Basser: 57:40

You know I got zero percent of a scar on my face. You know things like that. So we can discuss that. We can discuss that. Good Guys, if you want to get a hold of Bethany, her website is wwwvalor4vetcom. You can reach her that way. If you want her to get you, do you an IMO? You can join her portal. They'll contact you guys and talk and you know see what you guys need to do and you know she'll help you out that way too. She's got a lot of folks working with her. She's got podiatrists, she's got a whole bunch of folks. She's got CAs, nps.

J Basser: 58:27

Audiology all kinds of them. Yeah, so, but other than that. So we've got about a minute left, bethany, anything else you want to say before we shut her down?

Bethanie Spangenberg: 58:41

I think we've covered it all. I appreciate you having me. I know it's a lot of information, but I hope at least one person finds it helpful.

J Basser: 58:47

Thanks so much. Okay, I want to get you ready to get together. They do the weekly show or every Tuesday they do the show down in Tennessee. It's on the airwaves. I think you might be a good guest for his show.

Ray Cobb: 59:05

Love to have you to come on, mm-hmm.

J Basser: 59:08

I'll have to talk about that, yeah we'll schedule you on it.

Ray Cobb: 59:13

And it's an hour show about like this Okay, okay, well, all right.

J Basser: 59:20

Well, let's go ahead, guys. Thanks for listening today. We appreciate you. We'll see you again next week. On behalf of Bethany Springberg and Ray Cobb. This is John Stacy. We'll be signing off for now.

Ray Cobb: 59:31

Good night guys.

J Basser: 59:33

You have been listening to the Exposed Vet Podcast. Any opinions expressed on the show are the opinions of the guest speakers and not necessarily the opinions of Exposed Vet. Exposedvetcom or Blog Talk Radio. Tune in next week for another episode of the Exposed Vet Podcast. Thanks for listening.

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