Ray Cobb: 0:00

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 M Ray. Welcome, ladies and gentlemen, to another episode of the Exposed Vet Radio Show on this beautiful Thursday, march the 7th 2024. Don't forget this weekend to spring forward. Set your clocks forward, unless you live in a state that doesn't do that. If you live in a state that don't do that, you need to leave your clocks alone because you don't want to get to work too early.

J Basser: 0:40

But, anyhow, today is Series 2. We're working on DBQs. We've got Mr Ray Cobb, our co-host. How are you doing, Ray?

Ray Cobb: 0:49

I'm doing great. It's a beautiful day down here. I was looking over here at the chart and I see down here in my area that Bill and Paula are listening in tonight, so that's good. Glad to have them on board.

J Basser: 1:03

Yeah, that's good. We're getting quite a few folks in the queue. I've seen James get in there. He is. There's Mr Crips, he's popping in too and he's got his hand up, so I guess he wants to.

Ad: 1:15

Anyhow.

J Basser: 1:19

Yeah, okay, Now we've got one of our favorite people on tonight. She is a Valor for Vet. Any way you want to look at it, when you look at Valor for Vet, I think of Bethany. I don't think of Valor for Vet, but she's been a friend for a couple years now and she's a physician assistant. She owns Valor for Vet and she's going to give us a rundown on another DBQ. I think we're going to discuss heart disease, Is that right, Bethany?

Bethanie Spangenberg: 1:49

That is correct.

J Basser: 1:50

All right. So well then, let's go ahead and get you started, because this is a big topic, because everybody on here that I know is service-connected with heart disease.

Ray Cobb: 2:00

Yeah.

Bethanie Spangenberg: 2:03

It is a big one. It is a big one, so'm. Actually I have 10 pages. So what I wanted to do is talk predominantly about the ischemic heart disease and a little bit of heart failure.

Bethanie Spangenberg: 2:17

If you've got some extra time, I'll circle back to the arrhythmia and then we can touch on a few other things, but I mean there's like 20 plus diagnoses and there's multiple sections I really want to focus on. You know what, what the veteran should expect, what kind of questions they should expect, and you know what evidence they need to bring to their exam before this disability. Okay, all right. So I've got the DBQ in front of me. If you don't mind, I'll just jump in and get started.

J Basser: 2:51

You all right, Ann, I've got it memorized. Oh goodness.

Bethanie Spangenberg: 2:56

All right. So, starting with page one of the heart conditions to include ischemia and non-ischemic heart disease, arrhythmias, vagular Disease and Cardiac Surgery. So this is the big DBC. It was released in June of 2023. And our first page starts off, like all the other DBCs, asking questions about the individual filling out the form and the provider a VA provider. Is the veteran that they're filling the DDQ out for is either regularly seen in that provider's clinic and is the veteran being examined in person?

Ray Cobb: 3:35

Now.

Bethanie Spangenberg: 3:35

I will say for heart conditions, most of them do not require a face-to-face visit. Some of them do. I prefer to do these in person because your cardiac history is typically a pretty long one and I think that when you look at your patient you can really see some of the secondary effects whether it's, you know, some oxygen deprivation or other components to their cardiac condition that you can appreciate in person. So for me, if I'm a provider, I want to do this DBQ in person. So that's the top section, talking about you know who's doing it. The next section, just like the hypertension DBQ as well, is the evidence section. The veteran should always have their evidence in the file prior to their visit for their disability of being. And when we look at the cardiac conditions, the big records that have the most valuable information are any type of emergency room records that the veteran may have gone to the ER for chest pain. So if they're there for chest pain, they're going to get worked up with some cardiac enzymes, a chest X-ray, an ECG. That information is valuable. So you definitely want to make sure that emergency room visits are in there, especially if it's related to having chest pain or heart issues.

Bethanie Spangenberg: 5:03

The next thing that I recommend as far as evidence is any type of procedure, cardiac procedures like cardiac tests, any type of stent placement procedure. I've had a couple cases where the veteran didn't have a stent slice because they didn't meet the criteria to have the stent place but because of the report in the cardiac catheter report I was able to confirm that they did in fact have a stent heart disease and met the criteria for that stent. So that can be valid. And then also, if you have cardiac ultrasound, like an echo cardiac drain, like an echo ultrasound, that's going to show the vascular, not necessarily the vessels themselves, but how the muscles are functioning in the ejection fraction related to the height. So if there's some type of vessel that's being blocked, it can affect a certain area of the heart muscle and you can see that on the epic. So those are musts when it comes to the evidence. A lot of stuff there. Any questions about that, any suggestions, all of you have it.

J Basser: 6:28

One question Was it 21? They changed the rating schedule. They changed the criteria for heart disease. It went from basically ejection fraction to MBT admit. Is that what I'm understanding?

Bethanie Spangenberg: 6:43

They did change it and I'm glad they did so, and we can talk about that towards, I think, towards the end, mainly because the current DBQ action map is what's in the N21 now. As always the 38 CFR never changed. So any other things or suggestions for evidence questions.

Ray Cobb: 7:06

One question, Bethany, there, when you were talking a moment ago about when they did your workup and everything, if they went in and they found two blockages, I know where I go to at Alvin C York if you have two blockages and they send you for open heart surgery and do bypass, but if you only have one, then they try to stent. Is that the case all over the country? Is?

Bethanie Spangenberg: 7:41

that a VA decision or is that just a local decision made at our local VA? That's going to be a decision at the local VA. That's gonna be a decision at the local VA and I think you know the biggest thing that it's gonna weigh on is the comfort of the cardiologist, the experience and what medical care is accessible to them. So if your VA has, you know, access to doing the more invasive procedures and then if something would go wrong, they have a resource to get you help immediately, then that's something that they consider when they decide on whether or not they're going to do a procedure.

J Basser: 8:19

It should also depend on where it's at in your heart too. Sometimes they can't get to your heart with a cast like that.

Bethanie Spangenberg: 8:25

Right.

J Basser: 8:26

Yeah. So, behind the heart or the widowmaker, things like that's hard to get to. Yeah, behind the heart, yeah.

Bethanie Spangenberg: 8:35

I will also say that there are standard agreements or like what do they call them? But like things that they will and they will not see at the VA. So, carolina Green, so for that specialty for cardiology, if there's certain things that the provider like, let's say the primary care provider, wants this patient seen for X, y and Z, that VA may be like no, we don't see those, we refer this to the outside. So it's just going to depend on each VA and what that cardiologist is comfortable with and what tools they have to treat the condition.

J Basser: 9:17

Makes sense.

Bethanie Spangenberg: 9:19

So I'm going to transition to the long list of diagnosis sections. Every DBQ has a diagnosis section and I'm going to start the very first one, and I can't emphasize this enough. The very first box for the diagnosis section says the veteran does not have a current diagnosis associated with any brain condition listed above. So the reason I bring that up is that if they look through your records and you have not provided adequate evidence to that provider's license that you have a cardiac condition, they will mark that box and they will move on. That is absolutely necessary. Meaning move on? Meaning that they won't see you, they won't follow you. They will mark that button that says no diagnosis and they will push your claim back to the VA for that later to make a decision on. So absolutely important that you get that evidence in front of the provider prior to you. The next few boxes.

Bethanie Spangenberg: 10:25

We've got acute, which means something that's happened in a short time frame, subacute, or old myocardial infarction, which is a heart attack. Then we have atherosclerotic cardiovascular disease Cue down. We have arteriosclerotic. So there actually is a difference between atheroscler, we have arteriosclerotic. So there actually is a difference between atherosclerotic and arteriosclerotic. They're very minor, so sometimes they're used interchangeably, but they both qualify for coronary artery use. One is where the vessel itself just sits really hard and stiff and the other one is looking at the plastoidal plaster. So within the vessel Then we have unstable and stable angina, which is chest pain, we have a coronary spasm, we have congestive heart failure, we have coronary artery bypass. Those diagnoses would qualify for a student heart disease or the coronary artery disease benefit. All right, I'm going to turn to page three and just jumping into the medical history. If you look at the DBQ itself, there's not enough room to put the full history in that box.

Bethanie Spangenberg: 11:44

And this is something that frustrates me because I have to to try to cram all the history into that box and a lot of times those with coronary um artery disease, the single part. There the history is not short, it's. You know, I started to develop chest pain and then something led to a set sudden need for a heart stent. And they do three events of having heart stents over the last three years and they end up with a coronary artery bypass and they have some type of arrhythmia and congestive heart failure. So it's really messy sometimes and they don't leave a lot of room for the provider to put that information in there.

Bethanie Spangenberg: 12:24

So, going down further, for the medical history, they front up ask does the veteran have any condition that qualifies for a student heart disease? That's where they're trying to capture that presumptive condition, because that's predominantly where these claims are coming from. And again, I mentioned those conditions that I read off. Those would qualify for a student with heart disease. And then we jump down a little bit further. They want to know what other heart conditions that the veteran has and how it may be related.

Bethanie Spangenberg: 12:59

So for the heart condition, if the provider identifies that the veteran has congestive heart failure, then the provider would indicate the cause for that congestive heart failure. And there could be several causes for congestive heart failure. We do see it in ischemic heart disease. We see it a lot in bowel disease. We see it. We can see it in those who have hypertension, where the heart muscle changes and it's not doing an adequate job. That can lead to digestive health failure. It's not as common but I have seen it. And then there is a section there for the provider to lay out all the other cardiac conditions and what may be related to the acupuncture disease or to these other cardiac conditions, because a lot of the cardiac conditions are interrelated and they want that provider to lay the information out so that the rater can give the veteran the highest rating possible. All right, any questions about the history?

J Basser: 14:09

You know the congestive heart failure. I've had a lot of heart trouble. I actually won my ischemic heart disease back before. It was presumptive of aging orange. I had to go with the secondary diabetes route. I'm on my fifth defibrillator. The big problem now is congestive heart failure. I just got out of the hospital a couple of days ago. I had accumulated 24 pounds of water. Wow, it's tough. It is tough.

Bethanie Spangenberg: 14:52

That's a lot. That's a lot of fluid.

J Basser: 14:54

It's a lot, you know you get.

Bethanie Spangenberg: 14:58

Breathing, walking, moving. That's all of that.

J Basser: 15:01

Yeah, you can't breathe, you can't talk, you can't, you just can't do anything. And I got to thinking about that the other day when I got out of the hospital. I thought, gosh, three gallons of water. So I went to the kitchen sink and I drew up three gallons of water and let me tell you, I don't even I've got a bottle of water sitting here beside me now. I don't even want to take a drink of it. I'm full of water, but heart disease is that's one that you're not going to get over.

Bethanie Spangenberg: 15:52

Do you mind sharing kind of how your history progressed or developed in just the heart failure? I know that's a personal question, but kind of lay the story for what I'm talking about question, but kind of lay the story to what I'm talking about.

J Basser: 16:10

Yeah well, I was actually exposed to Agent Orange at Fort Gordon, georgia, and I got out of the service in 1970. I used to play music and I was playing harmonica one night in a band and my tongue got sore, my jaws got sore, I got sore down my throat and I just kept playing kept singing and it went away.

J Basser: 16:35

The next Saturday night my harmonica started playing music. Same thing happened. I looked at those harmonicas and I thought, gosh, I've got to germ in these things, I'm going to boil them out. But that turned out to be a full blown heart attack Two stents, bypass surgery, went back later, had a defibrillator, like I say, I'm on the fifth one now, but I'm still living. I'm still making plans. I opened the flyout to Biloxi, mississippi, monday.

Bethanie Spangenberg: 17:17

Took a little vacation.

J Basser: 17:22

You just got to have the right attitude to live with it and adjust.

Bethanie Spangenberg: 17:27

Okay, In my experience from the clinical side, when you get to the point of congestive heart failure, the medications really do. They're important in lengthening your lifespan and really controlling some of those symptoms and conditions that develop and congested heart failure.

J Basser: 17:50

My doctor tells me that my medications and my wife are the only thing keeping me alive. And he said, not necessarily in that order, but the side effects of the medication are not good, they're life-changing.

Bethanie Spangenberg: 18:16

Anytime you develop a, even just if you get a myocardial infarction or even if your cardiac staff shows a certain percentage of lossage normally the senior practices they throw five standard medications at you. And to start with, that can be very difficult to start to tolerate. You kind of have to allow your body to adjust to some of those medications. So, even if you have a little bit of heart disease or a lot of heart disease, there's always a lot of medication management that's taken.

J Basser: 18:53

You know, there is one thing that I would like to get out there. Should you ever find yourself in need of a pacemaker, advocate for yourself, Don't go with the pacemaker. Argue for the defibrillator. It's the exact same operation, just a little bit bigger unit, one more wire, and it's a lifesaver. It's actually saved my life twice now. It's a lifesaver. It's actually saved my life twice now. So you know, if you're going to have to carry around the weight of that defibrillator and deal with it, you know, go with the Cadillac.

Bethanie Spangenberg: 19:40

All right, so I'm going to transition into the next section on the bottom of page three. So you've already touched base on this section. It's myocardial infarction. Normally that's the first symptom or recognition of a veteran having some type of ischemic type disease. I've had patients in their 30s have an MI in the emergency room and it can happen. I'm not saying that to scare you, I'm just saying scare anybody that's listening. Just saying that normally that's the first onset. You don't always have symptoms of coronary artery disease prior to its onset. But healthy lifestyle, diet, not being exposed to Agent Orange or other toxins, is helpful. But there's only so much you can control in that and heart valve condition.

Bethanie Spangenberg: 20:33

Your ischemic heart disease is your predominant cardiac condition. You see, from the disability side. From there it triggers often ischemic heart disease, can trigger an arrhythmia. It is very rare that a heart condition starts to affect the heart valve. When you get in some of your more severe congestive heart failure, you can affect the heart valve. Severe congestive heart failure, you can affect the heart valve. But on the order of occurrence it's going to be predominantly your ischemic heart disease than your redness in your heart valve condition.

Bethanie Spangenberg: 21:12

If I switch over to page five, we're looking at pericardial effusion. That is when you get scarring around the heart and that is not a common association with ischemic heart disease, itself normally secondary to an infection of the covering of the heart. You may see it with some of your open heart surgeries. It's a savage procedure but it's typically not that common and we really don't appreciate the presence of pericardial adhesions until we go back into surgery for a second time or if we're doing some type of imaging that would appreciate the adhesion. So it's not something that we see often in the medical side of things. The next section jumps into procedures. The next section jumps into procedures and it's talking about your. It talks about PCIs or percutaneous coronary intervention. Take a guide up to your heart and a cage basically to open that artery and to improve blood flow. Normally after that you're on blood business for a little bit.

Bethanie Spangenberg: 22:38

Depending on the type of stent that's placed, you may not have to have it as long. The next procedure is your coronary artery bypass surgery. Normally we call this a CABG. That's when they open you all the way down the chest from the top of your sternum typically to the bottom of your sternum. It's a pretty long scar. It's usually pretty deep and pretty thick. So if you have a CABG, the compensation and pension examiner should also be doing a scar reading and measuring the scar following the length of the width. They should be pushing on the scar to see if it's painful and looking to see if the skin is well-heeled or if you're having issues with irritation of the scar.

Bethanie Spangenberg: 23:21

The other procedures include any type of cardiac transplant, which we don't see a lot of with ischemic heart disease, the pacemakers and your defibrillators, which we do see in the severe ischemic heart disease or the arrhythmia. Again, that's targeting the heart valve itself. We don't see a whole lot of heart valve damage from ischemic heart disease. A lot of your heart valve damage comes from previous infections, some type of muscle like heart muscle abnormalities.

Bethanie Spangenberg: 23:57

So it's not allowing a good feel. There can get scarring on some of the I call them leaflets, the cusps that come down. That's typically what would indicate a heart valve replacement. Then we flip it over to page six. We have a few other procedures, but they leave it open for other procedures that were not described above. It's about hospitalization.

Bethanie Spangenberg: 24:25

The next section, which is Section 10, talks about the physical examination For the provider. This is always interesting because there's nothing in the physical examination component that actually affects the waiting schedule. So they ask for the heart rate, they ask for the blood pressure. They ask for the heart schedule. So they ask for the heart rate, they ask for the blood pressure, they ask for the heart rhythm. They ask for what they call the point of maximal impact, which is when you feel. The provider will feel the chest and try to find where the heart, the end of the heart, is placed.

Bethanie Spangenberg: 25:02

None of that affects what the individual veteran is getting for their cardiac condition. So it's interesting that some of these components are on there For me. I just do it because they ask. That's why I always want to do an in-person exam, but that's not always indicated for each veteran. But you don't know that until the veteran's in front of you. Is there any other pertinent physical findings or complications associated with the cardiac condition? Page 7 is when we look at diagnostic testing, looking at EKGs, test, x-rays, echoes, all of that we've talked about. They're just documenting the findings related to that testing. Finding related to that testing. The last section on page eight is where we get into the meat of the rating schedule itself. So that is the metabolic equivalent for METS testing and for this section I'm going to read exactly what it says on page two.

Bethanie Spangenberg: 26:04

For VA purposes, all heart exams require MET testing for interview days to determine the activity level at which symptoms such as restlessness, fatigue, angina, dizziness or syncope develop, except exams for supraventricular arrhythmia, which is when moving the arrhythmia to the body. If a lab record termination for METS by exercise testing cannot be done for medical reasons, then perform an interview-based METS test based on the veteran's responses to a cardiac X-ray questionnaire and provide the results they want. So I read that because 10 years ago this was much different and this is what John, you were talking about earlier, about them changing the rating schedule and how the METS testing and how they rate it as testing versus ejection vaccine. So 10 years ago the DBQ just outlined the METS and they were instructing the examiner to present the MET testing and what they would do. Instead of taking an interview-based MET, which is me asking questions of what the veteran is capable of, they would want me to reference the echo or the ultrasound and how well that heart was pumping. So if we look at ischemic heart disease, which is the blood vessels, that doesn't necessarily tell us how well the muscle is functioning. Yes, the vessels can affect the muscle, but you can have a mild, excuse me, you can have a severe ischemic heart disease and no abnormal muscle function. So they gave the veteran the benefit of the MET testing, which was subjective. I did a rebate. Then the veteran would get a higher rating. But if they gave a rating based off the ejections option then they would give the vaccine a lower rating.

Bethanie Spangenberg: 28:08

So now they have changed it to where they can either do an interview-based or an exercise stress test, can actually look and get a metabolic equivalence testing MEC, mets for from that exercise stress test. So now they've opened it up to say okay, have they done an exercise stress test or are you doing an interview to capture the METS? Are you doing an interview to capture the MET? So when we look at the metabolic equivalence testing, I'm going to read word for word some of the MET interviews.

Bethanie Spangenberg: 28:56

So when I am conducting an exam and I'm trying to get a MET score, I ask the veterans do you have any of the following? Do you have any of the following Breathlessness, fatigue, angina, busyness? Do you pass out? Do you have any other heart symptoms? Say yes, then that is a 1-3 mix. If they say no, then I move on to the next question and I ask the veteran, do you develop any breakfastness fatigue, chest pain, busyness, do you pass out or develop any other heart symptoms when you're mowing the lawn or when you're doing a brisk walk or even when you're doing a weeding into the yard? And if they say yes, then that's a three to five minutes. If I do they develop any breathlessness, fatigue, chest pain, dizziness, or do they pass out or develop any heart symptoms when they're walking up one side of stairs, if they go golfing without a cart or if they're push mowing their lawn? And if they say yes, that's a five to seven month.

Bethanie Spangenberg: 30:14

We're looking to see when the veteran develops symptoms.

Bethanie Spangenberg: 30:18

So if they didn't develop while they're using the power mower mowing their lawn, but they're developing it when they're push mowing and they have a 5 to 7 met, does that make sense?

Bethanie Spangenberg: 30:31

So when we look at the maximal met score, which is a 7 to 10 met, that means that the veteran they're able to do moderate bicycling, they're able to jog six miles per hour specifically or climb stairs quickly, so that's a seven to 10 month. So normally that's an interview base and so it's based off of what the veteran is telling you. So if the veteran is telling you that they develop chest pain when they're power mowing their lawn, but they don't develop chest pain when they're taking a shower, then they would sit at a three to five. If they have lung disease and they're developing that breathlessness when they're mowing their lawn, that's still an indication of cardiac involvement, so they would still qualify for that lower MET score. Now, those questions that I read are word for word in the DDT, so they tried to take those numbers and throw it into the rating schedule in order to set out a disability rating. John, you may be a little bit better at kind of explaining that.

J Basser: 31:49

Yes, we're good, so repeat that real quick.

Bethanie Spangenberg: 31:54

I'm sorry, I had trouble hearing you Let me get it. I look at the net scoring from a clinical side and I think that you may have a better understanding of what I'm trying to say from the non-medical side. And I think that you may have a better understanding of what I'm trying to say from the non-medical side. So I was just going to kind of. Have you step in? And kind of talk about that.

J Basser: 32:12

What she's saying, though I mean you know you can on an everyday basis, you know, with the vet. Say, for example, you would want a little incline, maybe your mailbox is probably 150 from your house and you walk to your mailbox and get your mail Walking down the hill. You know you're pretty much okay, you know you hobble a little bit, but you turn around and start walking back up the hill and you get 30 or 40 yards. Next thing you know, your legs start getting tired. You have to stop Things like that. That's also part of it, you know, and because your heart, you know it affects your vascular system too, and if your legs start to get tired, it's called quadulation and basically it's not strong enough to pump blood to the bottom of your body and return, and so your legs start getting really tired or get really weak and you have to stop, and it takes a few minutes to get it back.

J Basser: 33:04

Another issue is you eat. Once you eat, and especially if you eat a good amount of food, you can be sitting there and next thing, you know, you'll get short of breath and next thing you know, your pulse is going to take off flying really, really fast and eventually come back down and calm down, but that shortness of breath itself you may not have chest pain because in our situation, guys, we're diabetics and you know we probably won't feel chest pain, because I know a lot of diabetics that had heart attacks and died and didn't feel it, or had heart attacks and didn't know it. So does that make sense?

Bethanie Spangenberg: 33:42

Yeah, that's helpful.

J Basser: 33:43

You know, now that I've gotten old and got a few gray hairs, there's two ways to go about that. You know, I had plenty of warning, I had plenty of signs that I had heart failure and I just kind of pushed it back and didn't pay any attention. So I had to do it the hard way. I had to go to the heart attack and the bypass and the pacemaker. You know, I would strongly suggest just going ahead and asking your doctor to do a heart workup and not have to deal with all the damage to the heart after the infarction. Two ways to do it, guys. You know just just surrender and get the hard workup or deal with what you're setting yourself up for.

J Basser: 34:48

Now. You know there's two types of cardiologists too involved with this. Right, we've got a we call them plumbers for the regular heart doctors. Then we also we've got electricians they're called electrophysiologists. Fortunately the VA's got both. And if you have, you know, if you have issues with arrhythmias and things like that or pacemakers and stuff like that, that's the EP docs that take care of that. The plumbers are just the guys that do the heart cast and the stress test. So it all depends on who you see, at the VA or outside the VA. Heck, they even got drain surgeons. Drain surgeons, yeah, they do, they're great employees.

Ad: 35:31

Yeah, they do. They're big grade employees.

Ray Cobb: 35:35

I have a question I have to deal with all of them, you know. Yeah, when we were talking earlier about the change and, like Bethany, in your description of what you gave a moment ago, I rate between a 1 and a 3. Now, how does that relate to ejection factors? They gave me an ejection factor estimate around 45%. Is that about what that would equal out to, or has my condition worsened to that?

Bethanie Spangenberg: 36:16

So let's talk about the. You're the perfect example of what the VA was trying to do in the past. So, yes, you have symptoms at one to three months. That would give you a higher disability rating percentage, but the VA didn't like that. I can't take out what impact on your METs that your diabetes has, that your let's say, you have COPD, let's say that you have neuropathy, those are going to play a part into your METs. Well, the VA didn't like the MET testing because it would put you at a higher disability rating percentage and there's no way for us to separate out the severity of your COPD, the severity of your diabetes and what's contributing from the neuropathy. So they weren't able to capture just the function of the heart vessels themselves. So what they were doing is they and this is the N21, this is not the 38 CFR what the regional office decided to do is that they were going to start looking at the ejection factors.

Bethanie Spangenberg: 37:31

And this is the example I said earlier where you can have severe ischemic heart disease and have a normal ejection factor. So a 45% ejection factor isn't bad, it's not perfect. You want to see something above 55% to be normal. You're not too low on that scale. So if they gave you the higher disability percentage based on your MET, well, they can't separate everything else. So they started looking at the ejection fraction. So when they look at your ejection fraction they can say well, the ejection fraction looks specifically at the heart function itself. Does the ejection fraction only pertain to the heart and doesn't pertain to his COPD or his diabetes or his neuropathy? We think that ejection fraction is a better measure of cardiac function than a subjective med pass.

Ray Cobb: 38:28

Okay, that brings up another. Okay, that brings up another. How frequently should you have the echo in order like, for example, the last echo I had was probably four years ago and it agreed with what I had right after my surgery, which was the 45%. How often should you have an echo to show how that heart is doing and the estimated ejection factor?

Bethanie Spangenberg: 38:59

Normally it's on an annual basis. Once your cardiac condition is stable, they're going to do it on a one-year basis. If you're having other issues, they may do it more frequently, but if you're stable, every year.

Ray Cobb: 39:16

So if I hadn't had one in three years, I need to ask my doctor to give me one. Huh, you should Because.

Bethanie Spangenberg: 39:25

I'll see him next month.

J Basser: 39:27

Remember, ray? It's not based off of injection fraction anymore. They used to use injection fraction as a golden rule. Now it's uh, you know, the metabolic equivalent. So but what Beth is saying is, if you're, if you've got symptomology for yourself and she can get that condition and it shows one to three, then she can. The CMP exam has to put the same thing down if they ask questions, you know what other?

J Basser: 39:50

conditions you got, you know, because I mean, for example, mine's 35, and my diaphragm is paralyzed, so my oxygen level drops when I start moving. So I think I should be 100%, but I just haven't done it yet. I don't think I should. But you know, it's just. You know, there's a lot of worms to open up and there's a lot of cans out there.

Ray Cobb: 40:17

Yeah.

J Basser: 40:18

Now mine was rated off the old ejection fraction, which was at the time 28%. I kind of think it's a little more precise than the metabolic method. But, anthony, you're talking about it including other things. But an old veteran like us, you know we don't walk the treadmill. They take us and they do the injection on the table that speeds our heart up Looks like that would isolate our heart and take the factors of neuropathy and leg problems out of the equation. That's a thing.

Bethanie Spangenberg: 41:13

So they don't like to do the chemical stress test because of the risk it poses to triggering a heart attack. So I've talked before about a case where that's what happened If you went for a stress test and they had to stop the chemical stress test to develop a heart attack and it was transferred to the local hospital for stent treatment. So, and honestly for the DBQ, the examiner may pull from a more recent exercise stress test. They may document one from five or six years ago, but they should still be asking these questions related to the mess. They should be asking about mowing the grass, taking a shower, things that you're capable of doing. Because they're not asking means that they're already against you, because it's right here in the GDC.

Bethanie Spangenberg: 42:12

And what they've added to the GDC, which is what I think is nice, is they have asked for that provider to use their clinical judgment to isolate what is fully related to the cardiopulmonary cyst.

Bethanie Spangenberg: 42:28

So they're supposed to write you know what you're saying, that you're experiencing, and then they're supposed to provide details about just the cardiac function as it relates to the other contributing conditions. The other part that I feel about this is I feel this may be more accurate than the injection process, because we're looking at inside the blood vessel. We're not looking at muscles. You can have a veteran who has had five cardiac stents on three separate procedures over a 10-year period and they're going to have a normal ejection function. Now, clinically we're looking at five stents three separate times. They're having an ongoing progressive coronary artery disease. So for me they're going to have a more severe ischemic heart condition than will ever affect their cardiac muscle because they're being proactive. So there is some debate on, you know, whether the MET testing is more accurate or the echo, looking at the heart muscle, is more accurate, and I tend to look at the MET.

J Basser: 43:49

Beth, I've got a question for you that than that. Beth, I've got a question for you. Is there any casual relationship to a veteran with chemical heart disease and low ejection fraction or you know, heart issues that also has a bad case of orthostatic hypertension? Do they play hand-in-hand and what's that bringing to play?

Bethanie Spangenberg: 44:13

So it can. Again, it's going to depend on each individual that's in the story. Sometimes it's going to come from how well the heart is pumping itself. But if the ischemic heart disease is severe enough that it impacts the muscle function, yes, you can have issues with your blood pressure Also with congestive heart failure. Not only the amount of fluid that you retain but the medications you are on to get rid of the fluid play a significant role in your blood pressure.

J Basser: 44:55

Okay, Basically, it's a lot of bit up and down, so we'll figure it out.

Ray Cobb: 45:03

Brings up another question AFib. My heart doctor told me that he had never seen anyone that had diabetes that didn't have AFib. Is that where it goes hand in hand, or does it come from a state of heart?

Bethanie Spangenberg: 45:21

So I think that's really up for debate, mainly because for diabetes in and of itself you have an elevated glucose within the blood vessels.

Bethanie Spangenberg: 45:33

Diabetics are known to develop that hardening of the artery that we talked about earlier, because the sugar molecules scrape along the blood vessels and the body's constantly trying to repair. So in that scenario you get that arteriosclerotic blood vessel, so it's going to harden. So then that scenario you get that arteriospirotic blood vessel, so it's going to harden. So then that's going to affect how well the oxygen goes from inside the blood vessel to the heart muscle, to the electrical function. We still have to maintain good oxygen exchange with the heart muscle, maintain good oxygen exchange with the heart muscles. So is the AFib coming from the hardened arteries associated with diabetes? Is it coming from any type of nerve damage that is triggered by diabetes? So there's a lot that actually plays into that. They say that the number one killer of your diabetic is a stomach heart disease because of the vasodilator that it does, and a lot of diabetics have silent heart attacks and heart problems because of that.

J Basser: 46:47

But it also affects your gastric too, doesn't it? Like, say, for example, you know your heart pumps your blood through your lungs and then brings oxygenated blood down to your lower extremities, but then it transfers over to a vein and comes back up, and if those vein valves are bad, then it's going to pull your legs and feet. It's going to have a hard time getting back to the heart, right?

Bethanie Spangenberg: 47:05

Right.

J Basser: 47:07

Okay, so it all runs hand in hand. Especially Okay, so it all runs hand in hand. Especially diabetes makes it worse too, guys.

Bethanie Spangenberg: 47:25

You see people getting their feet cut off all the time because of that. So I want to take a few minutes here just to finish up the little bit of what the DBC has left. So we're on the bottom of page nine. I've talked about the functional impact. Sometimes the provider saw a functional impact or the occupational impact that your heart condition has in your life. So I always tell my veterans put that in your statement, talk about how your heart condition impairs your ability to do certain things in a work environment or even for activities of daily living. Not only is that providing your statement, providing that evidence into the record for the heart condition, but if you're trying to apply for IU or aid and attendance now, we have in the record the troubles that you're having performing functional duties as it relates to a health condition. So always put that in your statement, put that into the record as evidence.

Bethanie Spangenberg: 48:25

The last section is just the examiner's certification and signature, just providing contact information for that examiner and then they leave most of page 10 blank, which could have been helpful to use in the history or something else. But if the veteran is being seen in person for this, this exam takes 30 to 45 minutes in person. If it's conducted by phone, it can typically take only 20 minutes. Any questions about that? P2p? Now I know we didn't get to the arrhythmias. I am going to provide some information on the arrhythmias. I don't know if I'm going to do that on like a separate audio or something maybe that we can share. To touch briefly on it. It would be another 10, 20 minutes to talk about the arrhythmias, but I think, talking mainly about the primary component and really emphasizing that these examiners should be asking the next question and if you're getting rated based off your exacting facts, then you need to take another look at your disability rating.

J Basser: 49:50

All right, you had an idea I like your idea.

Ray Cobb: 49:56

How would you do that, john? Would you come up and ask for a re-evaluation on your heart after you go to your heart doctor? And, like? I know that in my case I'm like James, I'm back when the ejection factor was the only thing. They went on and it was automatic that if you had had at least a double bypass and your ejection factor was below 50, that was a 60% rating regardless. Has this new way of doing it changed any?

J Basser: 50:29

Basically what she's saying is it? It changes because there are other factors involved. You know folks with lung disease and things like that. It all works together. Your heart and lungs work together. Say, for example, me my diaphragm is paralyzed and my heart has to pump blood through that lung. That lung doesn't want to take it because the diaphragm doesn't work to push the blood back out. The diaphragm helps your heart because it actually squeezes the blood through your body, so it makes it hard and it makes it a lot more difficult. So that's one reason why she's looking at it that way.

J Basser: 51:02

There's more factors involved and basically just the heart muscle itself is what the digestion practice is based on. Because it's based on what the heart's comfortability of the heart by itself based on. Because it's based on what the heart's comfortability of the heart by itself. Okay, she's thinking that the metabolic equivalents also include the vascular structure, the vessels, the ischemic heart disease, which is the intoxications or the plaque inside your arteries causing your you know, causing your heart to have to work harder just to pump blood through it. Is that what you're saying, betsy?

Bethanie Spangenberg: 51:33

Yes, that's what I'm saying. Keep in mind what the rating schedule says about the MET. So let me look at the 38 CFRs. We talked about a MET of three or less. So we're looking at let me pull it up here. So we're looking at, let me pull it up here. If you are developing, I'll take the pages out there we go.

Bethanie Spangenberg: 52:03

If you are developing breathlessness, fatigue, chest pain, dizziness, passing out or other cardiac symptoms while you're taking the shower, dressing, eating, slow walking, which is two miles per hour for one to two blocks, okay, that's actually quite a bit. So if you're doing any of those things and you're developing cardiac symptoms, that is a 100% disability. Later, if you are developing breathlessness, fatigue, chest pain, dizziness or passing out, any other cardiac symptoms while you are weeding in your yard, if you're doing a brick walk or power mowing your lawn, that is a 3 to 5 METS equivalent and that is a 60% rating. From the conversation we've had, it sounds like that you're getting those symptoms while you're eating, dressing, taking a shower, slow walking. That puts you on 50% Yep.

J Basser: 53:04

Bending over does it too.

Ray Cobb: 53:06

Yeah, it does.

J Basser: 53:08

Right, you know, my wife has to help me up and there's and somebody yells timber. Well, you know, my actual rating is for an implanted cardio defibrillator. I don't think I have a rating. Yeah, I've been in constant AFib since 97. Ischemic heart you will get a heart. Yeah, I've been in constant AFib since 97. Ischemic heart disease, all kind of rhythm problems, but my only rating on my heart is the implanted defibrillator. Right, that's all I need, you know.

J Basser: 53:51

Until we get R3 and then you get that James. Well, you know you could pile on all the other conditions and it's not going to raise your percentage. I think they get one rating for the heart, don't they, Bethany?

J Basser: 54:10

So you wouldn't, have a 104 implanted cardio defibrillator and then another one for ventricular rhythm problems and stack another one on for AFib, and I think there's only one rating possible at 100%. If we called that an Egyptian rating, james, that'd be paralytic. But Bethany, here's a good one now. Okay, say, for example you've got AFib, I've got it, I'm sure Ray's got it and James has got it. You can also have more than one type of arrhythmia too.

Bethanie Spangenberg: 54:55

Yeah, I don't know if that would benefit you on the rating schedule, but yeah, you can definitely have more than one. I don't know the whole diabetes and ACEN together thing. That doesn't expect me too much.

J Basser: 55:14

Well, we're part of the eloquent army, I guess they call it. Well, if you're going to have V-fib, you best get you one of them defibrillators.

Bethanie Spangenberg: 55:23

That's the arithmetic you definitely do not want.

J Basser: 55:29

That's the main reason for the defibrillator, James. That's kind of an automatic. They'll give you a defibrillator for other reasons, but it all depends on the condition. Like I say, you have to argue, you have to ask and advocate for yourself to get the defibrillator over the pacemaker, because the first thing they're going to want to do is put a pacemaker in Well you know that's fine and dandy, but it doesn't take the place of defibrillator. You know.

Bethanie Spangenberg: 56:12

I will tell you that insurance is probably what drives that more than anything.

J Basser: 56:16

Oh, if she can send that. I was actually on the table having a. I was supposed to get a replacement pacemaker. I was supposed to get a replacement pacemaker and in the middle of the operation, with my chest open, I asked the surgeon are you putting in a defibrillator or a pacemaker? And he said I'm under the understanding to put a pacemaker in. I said I was under the understanding you were going to do a defibrillator. He said hold on. And he went over to the telephone, made a phone call and he came back and he said young man, you just turned yourself a defibrillator. So he's putting the defibrillator in and it jumps out of his hands. I saw it go up in the air and he said man, I wish I'd have known that to start with. I'd have cut that pocket a little deeper.

J Basser: 57:23

Oh man, one important thing before we go the rating schedule with Phil now. You used to say that any medical test you have, there's a difference between the heart cath and the echocardiogram. The echo is a ultrasound look at your heart, but the actual heart cath itself is actually going up into your vessels with a catheter to a catheter looking at each vessel. So the echo is not. So basically, the heart cath is a boss test so it carries more weight. Yeah, it's the gold standard. I had one of those a couple of days ago. You know they go through your neck now. It used to go through your groin.

Ray Cobb: 58:16

I used to do my arm one time.

J Basser: 58:18

You know you feel a little bee sting and that's it. You know you feel some tugging, don't you?

Ad: 58:27

Yank, yank, yank tug, tug.

J Basser: 58:30

I do. I didn't hear you. You feel some yanking and tugging and things like that and they move that. Yeah pulling and pushing, pulling and pushing. But they give you that happy juice and you don't care. Oh okay, you're the mighty morphine Power Ranger.

Ad: 58:46

Yeah, no.

J Basser: 58:51

Beth, have you ever worked in a hard cast lab?

Bethanie Spangenberg: 58:53

No, I have not.

J Basser: 58:55

That would be an interesting thing. Get into it, that is one happy place.

Bethanie Spangenberg: 59:00

I've seen one. I don't want to participate A lot of things are going on.

J Basser: 59:05

People are talking and laughing and joking and you know there's some good crews down there doing that kind of stuff. What my wife used to run, the film james, he sits there with him all day long. She's the one that ran the. It's all live x-rays on the floor, but you're getting nuked while you do that, right, yeah, to them it's a big. It's a big joke to you it's. It's serious, but it puts your mind at ease. They're laughing and joking and talking and cutting up and it just makes you feel at ease.

Ad: 59:46

I've had a lot of all four of those people.

J Basser: 59:57

I hate to say this, I might have some bad news. No-transcript. You know, we get this thing like this going, but I guess we'll have to come back next month and do another one, doesn't it?

Bethanie Spangenberg: 1:00:16

That sounds good to me.

J Basser: 1:00:18

All right. So I don't know which one you want to tackle, but the further you go, the harder they get.

Bethanie Spangenberg: 1:00:25

I know, I know I was looking at that. I'm actually thinking we're going to touch purple vascular. Stay with the vascular and get it knocked out because there's only three of them.

J Basser: 1:00:35

Vascular okay.

Bethanie Spangenberg: 1:00:38

That's your varicose vein, your peripheral artery disease.

J Basser: 1:00:44

Cover Raynaud's too, if you can. A lot of diabetics get Raynaud's for some reason, that's when you turn purple and black.

J Basser: 1:00:53

Okay, I don't need to run an ending tonight, guys, it's not recording anyway. So that's good, we cut off right about the good time and uh, but it was a really good show. Hope people learned something. Especially these heart disease folks need to Get a handle on it and see what what they can come up with. As far as what they're ready for I don't think I am. I don't think Ray is either what they can come up with. As far as what the rating of the rating track is, I don't think I am, I don't think Ray is either.

Ray Cobb: 1:01:20

Well, it's not going to help me to get any higher rating. I mean, when you're an R2, you're an R2. Like you said earlier to James, unless they come out with an R3, we're stuck.

J Basser: 1:01:34

We should advocate for R3. We're stuck. We should advocate for R3. We need help doing that. Let's get us an R3. Maybe even an R4. Which I'll probably use for the Star Wars writing. Call you R2-D2. There you go.

Bethanie Spangenberg: 1:01:47

I like that.

J Basser: 1:01:51

You've already got mechanical parts in your body. You'll be a robot, sure. You know, at the point that you're going hard to pay. You can't, you can't kick on that. You know that's very good pay, very good compensation. It compensates me for my disabilities, but it doesn't take care of my kids.

J Basser: 1:02:24

I hate the fact that it's affected my kids. It's actually been passed down to them. There is no compensation level to make up for that. Let me tell you a good one, james, back when they were doing the Revolution TV show, we was involved in that and one of the actors was doing those lines and basically his character was an executive for Google and he owned a jet airplane. And they were climbing onto a jet airplane and he was telling the girls what he'd been and stuff you know, and that he was a millionaire and he owned his airplane and he said he'd try to get it all right now for a roll of Charmin.

J Basser: 1:03:16

So I mean if I could get your health back. You know I volunteered my time and I knew what the dangers were and you know we were in a dangerous business. But I didn't volunteer the lives of my kids, never contemplated. But I didn't volunteer the lives of my kids Never, never contemplated that it would affect them. Agent Orange, bad stuff, ray. I think there need to be more things to respond a bit to that. It's a list, to tell you the truth. Well, you know they've actually come up with a Vanderbilt professor in her lab actually wrote the novel that I'm in Lives Intertwined. They have come up with a way to replace that strand of DNA that Agent Orange has erased. I need to talk to her and find out more about it, find out where that research is going you mentioned that before.

J Basser: 1:04:29

That would be amazing to find that out. Buddy, let me get that doctor on the show. Let's interview her. She says they have it done. At the Vietnam Veterans Welcome Home Day celebration she was a guest speaker and she says they have separated that gene out and they've figured out a way to stop it in the bloodline. She is on my website along with her contact information. She runs her own lab at VA Medical University, vanderbilt. Yeah Well, she's got the right place. You've got to be a warm, important, smart cookie just to walk into Vanderbilt. Well, yes, you do. I met her at that celebration and I wanted to buy her books. She wanted to know. When I was in Vietnam. I said I wasn't in Vietnam, but I won the very first Agent Orange claim in the continental United States.

J Basser: 1:05:53

So she reaches over and grabs a volume, flips it to chapter 67. She said you're in my book. That's why I never thought she would meet me and I didn't know the book existed. Now you do, oh yeah you do. I bought the set of books. Well, you got number one and number two here, so that's good.

Ad: 1:06:17

Yep.

J Basser: 1:06:18

Yep. Well listen, I'm going to go ahead and shut her down. Guys, you all have a tremendous weekend, march Friday Enjoy the rain, because it's coming.

Bethanie Spangenberg: 1:06:29

Mm-hmm Yep. But let's do this again next month appreciate what you do yep, not a problem, thank you for having me and I appreciate the time. Hopefully it helped some one person learns.

J Basser: 1:06:44

It's worth it uh, you got more than one person learning. Then, lady, you're, you got a bunch, you got a bunch. I got all kinds of feedback. You're like, who's that young?

Bethanie Spangenberg: 1:07:00

lady. I appreciate that.

J Basser: 1:07:01

Okay, all right. Well, let's go shut them down. Everybody, have a good evening and we will take off. We'll see everybody again next week alright, sounds good.

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