Ray Cobb: 0:00

Love Talk Radio.

J Basser: 0:03

It's time for the Exposed Dead Podcast. The Exposed Dead Podcast discusses issues related to today's veteran. To call into the show, dial 515-605-9764. Now here's your host, John and Gerald. Welcome, ladies and gentlemen, to another episode of Expose that Podcast. Today is July, the 6th, 2023. The year's going by fast. I hope you guys enjoyed your week and I hope you got to blow something up the last couple of days. That's always fun, but today we've got our co-host, Mr Ray Cobb, out of Tennessee. How are you doing, Ray?

Ray Cobb: 0:46

I'm doing great. How are you doing today?

J Basser: 0:49

Oh, we're just putting one foot in front of the other.

Ray Cobb: 0:52

Keep on moving, I understand that If you don't talk about it, you'll be all right, yeah. Yeah.

J Basser: 0:58

But today we got an interesting topic. We got Bethany Spangenberg on there she's a PA and she is a battle for vet and we decided we were going to discuss the issue of GERD. If anybody knows what GERD is, it's basically a gastric reflux.

Ray Cobb: 1:17

And I know.

J Basser: 1:18

I've had it. I'm sure Ray's had it. I'm going to say everybody's probably had it one time or another. Bethany, what is GERD and what causes it?

Bethanie Spangenberg: 1:28

Well, hello, everybody.

Bethanie Spangenberg: 1:30

So, definitely wanted to talk about GERD because we offer the online DBQ and a lot of veterans will come back and say well, I want this box marked and this one checked, and so I'm like you know what? Let's talk about it. Let's talk about the DBQ and what GERD is. So GERD, or gastroesophageal reflux disease, often called heartburn, is the acid from the stomach coming up into the lower part of the esophagus and causing discomfort, and that can look like many things. It can just be symptoms of chest pain. You can have some stomach pain. Most frequently, people experience the burning sensation, like their chest is on fire. Some may feel the food come back up and there's certain degrees and what it is is that lower. We call it the LES or the lower esophageal sphincter, so the little muscle that's supposed to keep the food down at the very bottom of your esophagus isn't quite doing its job.

J Basser: 2:42

I can see that.

Bethanie Spangenberg: 2:47

What else is it that's stop doing the job? So there's a lot that goes into that lower esophageal sphincter either malfunctioning or not working the way it's supposed to. I mean, there's a long list, so it could be the types of food that you eat. It could be excessive alcohol. Fatty foods or red sauces are a long list, so it could be the types of food that you eat. It could be excessive alcohol, fatty foods or red sauces are a frequent complaint. If you eat too late in the evening and you go to lay down, if you have medications that kind of irritate the stomach, you can have the esophageal sphincter will dysfunction.

Bethanie Spangenberg: 3:26

The esophageal sphincter will dysfunction If you have diabetes. You can have motility issues that cause it. If you have anxiety or depression, that can cause some issues with that excessive acid production, you can have gallbladder disease and it doesn't digest correctly and so that fluid sits in the stomach a little bit longer and there's a lot that plays into it.

J Basser: 3:54

I think you just described half of my life right there.

Ray Cobb: 4:02

Does age have anything to do with it?

Bethanie Spangenberg: 4:08

Say that again.

Ray Cobb: 4:08

Does age have anything to do with it?

Bethanie Spangenberg: 4:11

It can. As we get older, those muscles don't work as well, and so you can get some additional or worsening reflux as you age. They say smoking plays a part in it. I think they say smoking causes everything.

J Basser: 4:29

So I mean that's another one. Smoking causes everything I mean it's.

Ray Cobb: 4:36

You know, it's almost as bad as alcohol.

J Basser: 4:38

Well, yeah, it is Alcohol caused it too, I mean.

Bethanie Spangenberg: 4:41

I've known terrible alcoholics that had it. There's two conditions that they've seen where smoking has helped, and one of them is Crohn's disease. They've noted that people who smoke with Crohn's disease don't have a severe disease. And then they've noted that smokers tend to have some protective mechanism in their sinus cavity and it has to do with the smoke actually coating the sinus cavity and preventing some allergens and irritants from impacting that tissue. So other than those two things they say, smoke causes everything.

J Basser: 5:20

Smoking causes everything. Wait a minute, that's an interesting story there, bethany, because you know in the 40s, 50s and 60s, you know most everybody smoked right and you didn't have this big influx of allergies and things like that until maybe the late 80s, early 90s, things like that it exploded. I think you're on to something. I'm serious, you should be on to something. I mean, you know people stopped smoking, they quit and they made cigarettes bad and things like that and put the. You know. Next thing, you know people quit smoking and had kids and didn't smoke. Next thing you know they're at the hour just getting shots three times a week well, I know my.

Ray Cobb: 6:10

That's an experience, uh uh. I've never smoked um. My parents spoke for chain smokers. They had no allergies, but I have allergies and I never smoked, and all three of my children have allergies. So yeah, maybe there is something there.

J Basser: 6:31

Yeah, there's something there, there's something there, I don't know, Maybe we'll have to do some research, but you know what's going to happen after we? I don't have that kind of data to make that type of opinion, but I hear you. I think that's just out there, far enough in left field. It might deserve a second look.

Ray Cobb: 6:59

John, you're pretty good. Why don't you contact your congressman, your good friends with him, and get a large grant so Bethany can do the research on that and come up with a conclusion? You know, get her one of those $2 or $3 million a year grants and let her go to work.

Bethanie Spangenberg: 7:17

Well, that's a.

J Basser: 7:17

HIPAA violation. That's called a HIPAA violation. It's called hands in pocket, pass around, pass around.

Ray Cobb: 7:24

Oh the.

J Basser: 7:24

HIPAA violation is called hands in pocket pass around.

J Basser: 7:29

No, hey, I've had dirt a lot, you know. I mean I've had, you know, heart issues and you know, diabetes and uncontrolled hypertension most of my life and I used to take certain medications but I was going to die. I mean I would get, I mean you'd feel like you just it boiled, I mean it, just it burned you up and I was at the point of getting the baricisophagus once and it would come close. And that's something you don't want, you know, because that can turn into it, that can cause cancer, can't it?

Bethanie Spangenberg: 7:59

It can. It's actually so when an individual has acid reflux that is not controlled what happens is the tissue just above the muscle, the LES muscle.

Bethanie Spangenberg: 8:13

The tissue just above it is not supposed to and injury to that tissue and you can get a stricture, you can get narrowing, you can develop Barrett's. And the way that they determine Barrett's is when they take a scope and they go down your throat and biopsy that material. Then they can take it under a microscope and the pathologist can identify whether or not that change in that tissue is consistent with Barrett's esophagus, which is a precancerous finding.

J Basser: 9:01

What does that say?

Bethanie Spangenberg: 9:03

I've actually seen Barrett's esophagitis is what they call it. But I've seen that quite a bit, especially in our veteran population.

J Basser: 9:15

Now you're kind of specialized because you do a lot of IMOs and things like that for the veterans, a lot of I am old and things like that for the veterans. What's some of the basically causes? Say, for example, I know that the bowel goes bad. I mean, you know it's each bowel. I guess that the muscles got to have a nerve controlling it. I don't know the physiology of it. But what medications are the most common causes of GERD for veterans? You know?

Bethanie Spangenberg: 9:46

So the number one at the top of that list is going to be your NSAIDs. It's going to be your ibuprofen, diclofenac, naproxen.

J Basser: 9:55

Vioxx Naproxen.

Bethanie Spangenberg: 9:58

Naproxen yep and aspirin.

J Basser: 10:00

Yep.

Bethanie Spangenberg: 10:01

Those are at the top of the list. Tylenol is a little less irritating but if you take your medicine without water, without adequate water, without food, it can cause an ulceration and it starts that irritation in the stomach area.

J Basser: 10:21

Yep, I've had that several times. I try to drink a little bit of something that would ease it. That's hard to do. Basically, I'll drink mostly water. I don't drink any of this. Sometimes I'll drink a milk, but I've had milk set it off before. Yeah, yeah, that's a good topic, of course. I'm sure between me and Ray, we probably got a pharmacy in our house. Oh yeah.

Ray Cobb: 10:54

I got a whole cabinet developed For it. You know this is a med cab, so you know that's where everything goes. Just sitting back thinking A few years ago, I guess it. It was probably eight or ten years ago now they were actually checking me for neuropathy and they had all the little probes hooked up and my arms were flying up in the air and all that good stuff. And when he finished I said, well, is it pretty bad? He said, well, it can't get any worse. And something else was said and then he said well, he said you know, truthfully, as long as you've had diabetes and the level of your blood sugars have been, he said, probably every muscle in your body has at least a little bit of neuropathy. Could neuropathy affect that muscle as well? And if diabetics have it, could it be because that muscle is weakened or not working properly because of neuropathy?

Bethanie Spangenberg: 12:02

So when you look at an individual who has had type 1 or type 2 diabetes over a prolonged period of time and they're starting to develop neuropathies. There's a type of neuropathy that's specific to the GI system and it's called gastroparesis. So basically, the motility, or the normal we call it peristalsis is how the muscles wave in their movement, but that gastroparesis doesn't allow, or that nerve damage doesn't allow, the bowels and the stomach to move like it's supposed to. So often that's the population we see gastroparesis in are the diabetics or who have been diabetic for a prolonged period of time. So, yes, once you develop that gastroparesis, that tells you that those muscles aren't functioning. And so the sphincter. There you actually have two sphincters one at the bottom, the LES, and then they call it a UES or the upper esophageal sphincter.

Bethanie Spangenberg: 13:04

So, you have two, that kind of control where that food is supposed to be and acid is supposed to be, and the gastroparesis can affect both upper and lower.

J Basser: 13:17

Would that be a claim for a?

Ray Cobb: 13:19

secondary to diabetic condition.

Bethanie Spangenberg: 13:22

Yes, that would absolutely be secondary to diabetes. When we look at gastroparesis, it's when we see that patient that well obviously diabetes is going to be you know, prolonged diabetes is going to be at the top of the list.

Bethanie Spangenberg: 13:41

But let's just say that you're not a diabetic and you're having some symptoms suggestive of gastroparesis. It would be infrequent bowel movements. You have persistent nausea, despite whatever medication that you're taking. You're having some heartburn reflux, some regurgitation, so something that kind of looks like GERD, and we can't quite get it under control, despite medications. They may do a barium swallow and that barium swallow you drink medication and then they take x-rays of that medication or that liquid over a period of time and so if we suspect that you have gastroparesis, we're going to order a barium swallow to be conducted.

J Basser: 14:23

That's floral, right? I didn't hear you. That'd be fluoroscopy Under live x-ray. You swallow it and you watch it go down. It's kind of like a sniff test.

Bethanie Spangenberg: 14:39

So this is a little bit different. It's not going to be a live picture, they're actual pictures. So they'll do like an x-ray. So they'll do an x-ray, then they'll wait 30 minutes, they'll do another x-ray, then they wait another three hours. They have different time periods based off of what the provider is suspecting.

J Basser: 14:57

And what you drink and when you drink. Yeah, I see it more Guys, I'll tell you what this stuff is probably the raunchiest stuff you ever stuck your lips on. They used to have a nice orange flavor at once. I've had it all done, it just didn't look fun. You know it ain't happening now, but now this is a bagel. I guess it's the nerve. Is the bagel nerve that actually innervates that valve or whatever it is that muscle? I've heard people have a vagal reaction and things like that. That's probably the same nerve.

Bethanie Spangenberg: 15:37

The vagus nerve controls a lot it controls a lot Cool.

J Basser: 15:44

I didn't study that. But now how would a person diagnose that? I mean, could you do an EMG down that way?

Bethanie Spangenberg: 15:50

That'd be hard to do, wouldn't it? No EMGs, but they. Barium swallow is normally the standard of capturing that diagnosis for gastroparesis. There are other tests, more specific tests. It's going to be specific to like a gastroenterology practice or department for doing anything fancy, but your barium swallow, your EDDs, those are two of your standard tests for most workup of stomach complaints.

J Basser: 16:21

I wonder if that's even in the rating schedule from the VA? I've never seen it. You ever seen it? Right For gastroparesis? I wonder if that's even in the rating schedule for the VA? I've never seen it. You ever seen it right For gastroparesis?

Ray Cobb: 16:31

Yeah, I haven't.

J Basser: 16:33

I personally have not either. Of course, there's a lot of things the VA uses. There's a lot of generic things they use too. You know, rate this, this, that or whatever you know. So it'll cover everything. That's a good question. Anybody service an activist and maybe eventually send us a message and give us some information about it, because I've never, you know, it's possible, especially with diabetes, bad stuff.

Ray Cobb: 17:02

Well, yeah, and now you're looking, I mean we are really coming up on some, you know, 40, 50, and 60 years for some of those that were in Vietnam. That was with Agent Orange, which brought on both diabetes and heart conditions, and I think both of those, my understanding, can contribute to what they refer to commonly as heartburn or indigestion. And especially, like you and I were talking the other night, John, spicy foods and being a diabetic, the spicy foods really bother me a lot. As a matter of fact, I just stay away from them, you know. I just you know.

J Basser: 17:51

That's a good question for Bethany. You know, do spicy foods bother you, Bethany?

Bethanie Spangenberg: 17:56

They do, but I'm also diabetic and.

J Basser: 17:59

I actually started having heartburn with pregnancy so oh, okay, well, I don't know, Maybe you're going to have to stop that. I tell you that's bad stuff, you know, but it is. I mean diabetes. That whole thing just sucks, you know, because I mean you try to keep it under control and if you slip up, you know, I mean I know a fellow the other day had to go to the emergency room because his is 900.

Bethanie Spangenberg: 18:30

Oh, how is he not in a coma? I?

Ray Cobb: 18:34

had no idea. They got a baron. I went to VR one night, mine registered 1150. And they were running around me like a bunch of chicken with a head cut off, didn't know what to do. And you know, they started an IV and started giving me insulin directly into the vein and finally got it down. But it took them from about 9 o'clock in the evening in the ER and they let me go at 7.30 the next morning.

J Basser: 19:06

Wow.

Ray Cobb: 19:07

And then it was only only it was still 220 they don't know they really don't they never said first thing. They said well, did you drink any alcohol? No, I didn't. You know. That was their first question. That wasn't a played a part of it.

Bethanie Spangenberg: 19:31

We're the first ones to ask it.

J Basser: 19:32

I mean, they're trying to find some type of weapon of conduct on you. You know that you're going to be out, yeah.

Ray Cobb: 19:44

I'm sorry, but that's true. Yeah, well, what have?

J Basser: 19:46

you done to kill yourself, you know?

Ray Cobb: 19:50

Yeah, yeah, yeah, and that's the first question. The second question when did you take your medication when you ate tonight? Yes, I did. Or is your medication good? Well, I don't know, I can't tell by looking at it. I remember I smarted off with the guys you know, I don't know.

J Basser: 20:12

I've been off with the guys. I know I've been there, done that. But you know, if you've got a good trump card in your back pocket, you're okay though, because sometimes you don't have to worry about going to certain places. You can go anywhere you want to go.

Ray Cobb: 20:23

Yeah.

J Basser: 20:24

And that's a, you know, that's a good thing to have. You know people are like, oh, I don't need this insurance, I got the VA. Yeah, okay, that's fine, buddy. No, I'm going to kind of straightforward you though. But I mean this is bad stuff. I mean, you know, if this stuff gets up to your throat, your esophagus, and it burns for a while, it could cause baricosophagus. And if you don't get it treated, you probably will get cancer. And everybody I've known in my lifetime including several family members, some really good friends, especially some couple Korean vets they all develop throat cancer and they all died. One of them lived for a little bit, but I know I had an uncle who was an alcoholic and he developed it and they went in and did a removal. They took everything out. You know he couldn't. You know he could talk a little bit, but everything else was out, and they gave him a feeding tube in his stomach.

J Basser: 21:26

When he didn't quit drinking. He quit drinking and started pouring.

Ray Cobb: 21:29

He would pour a week to get into that tube, oh gosh.

J Basser: 21:33

Yeah, but he has been passed for a long time, but you know, he was an Army retired Army vet too, so alcohol will kill you too. It's worth walking across the street and making it your too, but you know at least you can look both ways, unless you've had too, much alcohol. But I don't know. I mean, bethany, have you done a lot of on this BBQ. Now do you do those yourself? I mean, do you take them off the VA site and print them out and fill them out? How do you do it?

Bethanie Spangenberg: 22:12

So I actually GERD itself. If you just do GERD and you're not doing the hiatal hernia, we can too. But the GERD and hiatal hernia, if it's just those, those are actually ACE exams and so you can go online and you fill out the questions and then I will review the questions and fill out the boxes based off of your response. I'll review the file and then I'll send it back or I'll drop it in your we have like a Dropbox folder that we share documents with each veteran. Then I'll sign off on it.

Bethanie Spangenberg: 22:48

But that's kind of what prompted this topic discussion is because a lot of times there's a disconnect between what a veteran wants to see on their DBQ versus what has transpired in their medical history. So a veteran will click on a box or they'll get their DBQ back and they'll want me to change it to include the symptom specific. I'm reading it symptoms combination excuse me, symptoms productive of considerable impairment of health.

Bethanie Spangenberg: 23:21

because they're trying to get that 30%, they're trying to get up above the 10% level, the 10% level and what happens majority of the time is, I will see a veteran's response and then they'll tell me that they have all these symptoms. They'll tell me they'll have vomiting four or more times a year, 10 days, and it lasts you know how many times. You know for a period 24 hours or whatnot, but then they tell me that they've not had a barium swallow.

Bethanie Spangenberg: 23:49

They haven't had an EGD, they haven't had an evaluation from their primary care doctor, or the history isn't consistent with what they're telling me, and so they want me to check that box. But I need to know from a clinical standpoint that what you're saying matches your medical history. So on the clinical side, typically patients don't come in complaining of GERD until it becomes uncontrolled, until it becomes a lifestyle problem. It's interfering with their sleep. They can no longer eat spaghetti.

Bethanie Spangenberg: 24:34

They can they're waking up. So until it's a problem, they're not being seen for it. And so if a patient comes into the clinic and they're telling me they're having these uncontrolled symptoms, I'm going to do some lab work. I'm going to do some basic lab work. I'm going to make sure that they're tested for H pylori antibodies. It's just in the blood. I want to check a basic H pylori.

Ray Cobb: 24:57

I check them for.

Bethanie Spangenberg: 24:58

H pylori. That's part of the standard. I'll check a CBC, which is their blood count, and then I'll check their kidney function and make sure those all look where they're supposed to be. If they're telling me they have uncontrolled heartburn and they show that they're anemic or they have a low blood count, then I'm going to automatically refer them for an EGD. If it comes back positive for H pylori, then they're going to get an antibiotic and some antacids to treat that bacteria. If an individual comes back positive for H pylori, that particular bacteria has been identified as causing reflux symptoms, so clinically they should be treated with antibiotics at least once in their lifetime to treat that H pylori and then from there. Treating H pylori doesn't make the symptoms always go away, maybe get them back under control. But those are just some of the basic steps that their primary care provider should be doing with a complaint of uncontrolled reflux.

J Basser: 26:04

Does H pylori have something to do with the food you eat, or is it something that's geographical or what? I've heard several stories about it. You know especially people in like eastern Kentucky or in the hills and things like that. I hear there's a lot of cases of it, so it's just something.

Bethanie Spangenberg: 26:20

You know I don't know a whole lot about H pylori. To be honest, I just know from the clinical part if they have the antibodies we're supposed to treat it. My history and knowledge on H pylori is very limited.

J Basser: 26:38

Probably in South Africa too, you know, but there's a lot. I mean, people in certain parts of the country will have a higher incidence of it, from what I understand. But now do you take that treatment? Does it get rid of it, or is it something you've got for the rest of your life?

Bethanie Spangenberg: 26:57

So you'll always have the H pylori antibodies, and that's why, it's hard to like.

Bethanie Spangenberg: 27:04

You get your antibodies. They're positive, you get treated. 10 years from now, you're still going to have those antibodies. It's not going to necessarily say that that bacteria has come back or not. If an individual gets an EGD and they do a tissue biopsy during the EGD, where they stick the scope down, they can test that tissue for H pylori then. So, yes, we treat you, but we're not going to go back and monitor and do a scope every year or every few years just to make sure it's under control.

Bethanie Spangenberg: 27:39

Some people have they live with it.

J Basser: 27:43

I know some people have that gastric sleeve surgery and some other stuff and I know a couple of surgeons and one of their what they have to do before they even consider doing the surgery. They do the scope down your stomach. A lot of times they find H pylori and Spock had. It's a pretty invasive surgery so they want to make sure their bases are covered. I know a lot of guys that do that and they find a lot of issues, ulcers and things like that. So I guess they gotta cross their teeth and dot their eyes if they do anything so I want to jump back to the DBQ really quickly if a veteran is telling me that they're having persistent, recurrent epigastric distress.

Bethanie Spangenberg: 28:34

They're having dysphagia or difficulty swallowing, they're having the food come back up, they're having the chest pain. They're having all these symptoms, but they haven't had an EGD.

Bethanie Spangenberg: 28:46

That's concerning when is that EGD? That's concerning when is that EGD? From a clinical aspect, if I have a patient sitting at or in my exam room and they're telling me they have these symptoms, I'm going to refer them for an EGD. It's just part of the normal clinical care. So I'll see a lot of these DBQs come back and they're telling me they have all these symptoms and no EGD. So I want the history and the symptoms that they're reporting to match what's clinically appropriate.

J Basser: 29:16

That should be a protocol. That should be a protocol.

Ray Cobb: 29:24

Beth, we have a veteran that listens in all the time and as you're explaining some of that. If we have a veteran that listens in all the time as you're explaining some of that, my mind just immediately jumped to what I've heard him complain about for two or three years now, and I'm more likely he's listening in tonight. But he talks about the chest pains and he talks about sometimes actually having heartburn. But then a lot of times he talks about he just feels like there's something in his throat and he can't clear his throat. Some of the symptoms you're talking about kind of goes right along with that. I know he's on a lot of diabetic medication heart medication, antidepressants that I'm familiar with, that he's talked with me about. With any of those types of medications or he is a diabetic. He's been a diabetic for years. He takes insulin shots. They won't tell. They have not told him anything that would be causing this. What's your thoughts or ideas or what you might suggest that he do next if this heartburn is persistent on a regular basis?

Bethanie Spangenberg: 30:47

so if he were my patient, I would absolutely push for an EDD. The moment you tell me that he feels like he can't get the food down, that's concerning on multiple levels, because I'm wondering does he have a stricture or a narrowing in the esophagus? Does he have a tumor in the esophagus, causing it to where he can't swallow the food? Does he have a tumor in the esophagus, causing it to where he can't swallow the food? Does he have a hiatal hernia that's blocking the food or preventing the food from going down? Does he have? So there's a condition where you can actually get a hernia within the esophagus muscle, the esophagus muscle and that little hernia can pocket food and can cause damage to the tissue and actually put a hole in your esophagus. So if he were my patient, let alone difficulty put everything else aside, the single complaint of feeling like he's getting food stuck absolutely would want to look at his esophagus and down into his stomach to see what may be causing that issue.

J Basser: 31:54

If any veteran has difficulty swallowing.

Bethanie Spangenberg: 31:57

That would be something. And have an EDD. If you're losing weight and you're not trying to, you definitely need to talk to your doctor. If you choke when you eat, you need to have somebody look at your esophagus.

J Basser: 32:11

That's exactly how my best friend, if your GERD is enough to cause you to vomit.

Bethanie Spangenberg: 32:18

You need to have a scope. Sorry.

J Basser: 32:21

That's exactly how my best friend got diagnosed with cancer. He was trapping food and he couldn't swallow. He handled pain or nothing. He went to the doctor and he couldn't swallow, and he handled plain or nothing. Even he went to the doc and they put a scope down him and they gave him the bad news a few days later.

Ray Cobb: 32:42

I'll call this gentleman tonight in case he isn't listening. But, john, this is our friend that you and I both have talked with on several occasions that travels back and forth between Tennessee and Michigan the old GT. To give you an idea, mr GT.

Bethanie Spangenberg: 33:02

Yeah, the reason I push those EGDs so much is because it's really a valuable diagnostic tool, because they can go in and they can see how well the sphincters or those muscles are working. They can see if the stomach is irritated like gastritis. They can take a biopsy and see if allergies or food allergies are causing your reflux. They can see ulcers.

Bethanie Spangenberg: 33:32

They can see if the ulcer is up towards the top or lower down into the bottom of the stomach and they can help kind of figure out what's causing the issue, based off of where the ulcers are located. They can look for. Barrett's and make sure you don't have Barrett's they can test for the H pylori. So it's a valuable tool and if you're looking to get those symptoms under control, having the EGD to understand what is causing it will also drive the treatment and get those GERD symptoms back where they need to be.

J Basser: 34:06

I mean it's a pain in the procedure anyways, you won't know it. I mean they give you enough medicine to date you pretty good, so it's not bad, but it's, I think, everybody ought to have one. I think everybody ought to have one at least once every five years, regardless. I think it saves a lot of lives.

Bethanie Spangenberg: 34:31

I know we talked. I briefly mentioned a hiatal hernia, but the reason why the words hiatal hernia play such a role in the VA world is because that's how they rate you. They rate you for a hiatal hernia even though it's completely different than what GERD is.

J Basser: 34:51

I don't do that. I mean, like I said, you know they've got some ratings that are totally you have no idea. You know you look for a rating.

J Basser: 35:01

You don't see it. Then you start reading that says right, it has a hiatal hernia, or you know, they have conditions right under this coat for this and this, and it's kind of like trying to do an unsolvable crossword puzzle. That's what it is. It's very confusing, but I think they should at least one day update where they can get everything lined out, because it's been a work in progress for 60 years, 70 years. Now it is what it is. The VA race it from 10 to 60 percent.

J Basser: 35:41

You know what yes you and get 60, you've got to be in pretty bad shape, so. I've seen a few 60s, lots of 10s that's the J's favorite number, 10, when my favorite number is 0. True they have a hard time writing that one in front of that zero to get ten, and the higher the number goes, the harder they have writing it. No, I'm just kidding. Gotta have a little humor in life, people Not being.

Ray Cobb: 36:27

Gee whiz. I thought the VA rating system was always a him right. I didn't know. They ever got serious. I don't know now.

J Basser: 36:37

Have you ever done VA math Ray?

Ray Cobb: 36:40

Oh yeah, I'm quite familiar with how the VA math works.

J Basser: 36:46

They've got their own math, their own language.

Ray Cobb: 36:48

Have you had the VA calculator?

Bethanie Spangenberg: 36:54

I've got to tell a funny story about VA math. So, I was looking for a product. I wanted a product that kind of made Valor for Vets stand out and be different. So in my head and I don't know if we talked about this before I'm trying to make Valor for Vets stand out and be different. So in my head and I don't know if we talked about this before I'm like I am going to have a custom 8-ball made.

J Basser: 37:18

Okay.

Bethanie Spangenberg: 37:19

And I did. I had a custom 8-ball made, but you can't get them in the US. You can't get a custom 8-ball made in the US. You have to go outside of the United States to get a custom 8-ball made in the US. You have to go outside of the United States to get a custom 8-ball. So where did I order my product? From China.

J Basser: 37:39

Oh, okay.

Bethanie Spangenberg: 37:40

So I ordered custom 8-balls with custom answers and I ordered them out of China. Answers and I ordered them out of China and on one of the sides of the dice that's like, or the whatever it is that's inside of it that gives an answer, I put like different sayings, like denied, I put service connected, 0%, I put wait like 1,360 days or something like that. That's what the average to get to the board was at that time this was a couple years ago that I did it. So each one had like a different saying and it was kind of, you know, playing with the humor and trying to make light of it. And so you know, the way I kind of sold it at our vendor shows is, whenever you go to put a claim in, you shake that eight ball up and you figure out what your, what your rating decision is, because that's how the va does it. So that's kind of like the humor.

Bethanie Spangenberg: 38:36

But the funny part of it was is I had proof. I got a, has the proof back and it was like 30 plus 20 equals 40. He kicked it back to me twice and he goes are you sure this is right? And I'm like yes, that is correct, Submit, approve, print them. And he kicked it back again Are you sure this is right? Are you sure this is what you want on this? And I'm like approve, print them. And he kicked it back again Are you sure this is right? Are you sure this is what you want on this? And I'm like, yes, 30 plus 20 equals 40. Please print it. So the VA math didn't make sense to this guy in China trying to print my custom eight balls, so it was comical to me. I don't think it was 30 plus 20, because that doesn't make the 40, but whatever the two numbers were, they weren't like logical math. It was VA math. So, whatever it was, it was just the fact that this Chinese guy was rejecting my proof because the math didn't make sense the math was off.

J Basser: 39:43

Yeah, well, that's what they get for running through Jethro Bolden, when they first made it up, you know, and he was quite the mathematician.

Bethanie Spangenberg: 39:58

Oh, it was 30 plus 30 equals 50. That's what it was, that's what he? Kept trying to reject.

J Basser: 40:07

It is 30 plus 30 is 50. I know the VA had an issue years ago. There was a lawsuit, probably 10 years ago. This guy, if you get to 100% and you go over 100%, like you're trying to go to the high-level S&Cs, they still use the combined rating schedule, they still use VMAF. They got lost in court for some reason. I don't know why I did, but still, you know, go out and do it and uh. So if you're sitting there at SMCS and don't have a loss of use or aid attendance, you can be 10,000%. It's still have SMCS.

Ray Cobb: 40:44

You know that I did a matter of fact. I think I was, I think I was about before I got my first aid and attendance or loss of use or anything or any of the grants you know I think I was like had two, maybe three hundred percenters and a couple of sixties and you know, didn't get any more money. I was talking to a county claim agent back at that several years ago about that and he said we don't give you anything once you hit 100%. We just pretend that it doesn't exist.

J Basser: 41:29

What. There's a sign. I've had people tell me that too. Bethany, you know what I say to them, what they tell me that. Duh, which way do we go, herman? Which way do we go?

Ray Cobb: 42:00

I was in a meeting.

J Basser: 42:00

One time they tried to run me out. Oh yeah, yeah, so, and these people are being trained in that perspective. Okay, and it's not the people's fault, it's the people's Trottingham's fault. Somebody's always driving the bus, pretty sad.

Ray Cobb: 42:15

I love the one that our local agent told me one time several years ago. He said well, I don't know why you keep trying or keep turning these claims in. You don't get any more money after you hit a hundred percent.

J Basser: 42:31

You don't. That's not not true, and I'm proving it they tell you that the disability scale stopped at 100%. You're looking at the VA compensation scale. They haven't turned the page to the special monthly compensation scale yet and a lot of them have no idea it exists. But you know. You start looking at housebound. You know the stepping stone to aid attendance or to any of the higher S&Cs goes through the channel called L. If you don't have an L, you don't have nothing. That's a fact, you know.

J Basser: 43:13

I mean that's a launching point. I mean there's a lot of vets out there that need it. You know that are. You know they have a lot of issues, especially having to have help of you know somebody to do stuff. You know if you need help with the activities of daily living. You know Bethany just said last time she was on she had just done a dependent claim at your business or an IMO. I sure did I did an exam Okay and it was funny because the veteran didn't want.

Bethanie Spangenberg: 43:46

He's like the VA has been good to me, they've paid me. He was at 90% and he's been at 90% for like 20 years because he got in a bad accident when he was in the military. And I'm like you don't understand, like you can't live by yourself, like you're not in a nursing home because your wife takes care of you.

J Basser: 44:09

And she's a caregiver right.

Bethanie Spangenberg: 44:12

Yes, she's a caregiver.

J Basser: 44:15

They should be paying her to do it. I hope.

Bethanie Spangenberg: 44:18

We haven't got that far yet, so she's kind of frustrated.

J Basser: 44:22

You don't have to be 70%, at least for a caregiver. You don't have to be 100%.

Bethanie Spangenberg: 44:28

So with her I've done like a stepwise fashion, because she's had a lot of issues with the paperwork. It's also the same one that's the caregiver for her grandson.

J Basser: 44:38

Oh, that's right.

Bethanie Spangenberg: 44:39

So she's had a lot of so she's had to juggle a lot. So we're doing it, giving her a break mentally, because it's a lot to deal with the VA.

J Basser: 44:48

She has a major on her too. I understand now. I remember that now it kind of comes back to me. But if you've got age attendance and you need help doing stuff and you've got somebody doing most of it, if they live in the house with you, take advantage of the caregiver program. If you meet the requirements, get in for it. You'll have to go through the interview process and be trained, but that's what it's all about isn't it, ray?

Ray Cobb: 45:16

It absolutely is, and it's definitely worth your while for multiple reasons that's going to benefit you and your family. So that's you know there's some long-term benefits there. That's you know there's some long-term benefits there that can really help you. I mean it can make a big difference in your life and your lifestyle and your comfort level.

J Basser: 45:43

There shouldn't be an R1 or R2 vet that has a spouse living with them and taking care of them. They should not be getting the caregiver program.

Ray Cobb: 45:55

Well, that's true. Today you're talking a total different concept and a total different philosophy of how they make those determination, and the thing that I have experienced is that in that caregiver program they don't even like to leave their own doctors. That's the only thing I can say. I mean, you know, your doctor says very clearly that your spouse or someone has to do this for you. Every time it's done, they say oh, I can be the court ten seconds.

J Basser: 46:34

You know what r1 and r2 the climates are? Well higher level of aid and attendance correct.

Ray Cobb: 46:44

Now they have some things that are higher.

J Basser: 46:46

But what I'm?

Ray Cobb: 46:49

finding out when you get to those higher levels which I experienced, what a month ago, a little over a month ago now, even the regional office don't even know which forms to send their doctors that are doing the CMP. They send them the wrong form and tell them the wrong information.

J Basser: 47:10

And you think that's a mistake, do you?

Ray Cobb: 47:13

Well, yeah.

J Basser: 47:18

I want to do a show. I want to do a call-in only show and, beth, you can join us. I'm going to advertise this out here and I want to say how many veterans have had a C&P exam that the regional office sent the wrong form. Basically, that light will light up like fireflies on a June night.

Ray Cobb: 47:41

Well, I'll tell you what. There's a good question about that. How many veterans have been rejected for aid and attendance or higher level of aid and attendance? And didn't even realize, because when I thought the questions were a little unusual, when I did my first C&P exam four months ago, five months ago, four months ago, five months ago but at the same time I had no idea that there was actually two different questionnaires and the only thing that threw me a key is when I made the statement that Pam had to give me injections and she said well that's not one of the questions I'm like whoa wait a minute there's something

J Basser: 48:29

wrong here, yeah, and then I had to go to Tony and they minute there's something wrong here, yeah. And then I had to get a turn. They didn't tell it all out. Yeah, if you can't get plunged and you can't do it, you get shit on the part. That's age attendance. And of course we've got a young lady on here that can back that up. You know, because that's her.

Bethanie Spangenberg: 48:48

You know, that's what she does, for you know she knows this stuff. So, Ray, what was it? Go ahead, no go ahead.

J Basser: 48:53

Go ahead.

Bethanie Spangenberg: 48:55

Ray, did you ever figure out what?

J Basser: 48:56

DBQs. They were.

Ray Cobb: 48:59

Did I figure out what test they were.

Bethanie Spangenberg: 49:02

What DBQs or what questions.

Ray Cobb: 49:06

The questions had to do with R. Well, I never figured out if it was standard aid and attendance or R1. I think it was standard aid and attendance.

J Basser: 49:17

Okay, higher level aid and attendance is what you should have had, right.

Ray Cobb: 49:25

Yeah, but there's two forms for higher level aid and attendance. That's the problem You've got too many stinking forms. Well, that's probably true too, yeah. But really the interesting part the first exam lasted 50 minutes. When they sent her the new questionnaire and we went in that when I got my letter said this will last approximately 50 minutes and we go out and sit down with her and she starts asking the questions. First question was why are you back here? And I said they sent you the wrong form.

Ray Cobb: 50:06

She said that happens all the time, and then I said, okay. She said, well, what is it you're applying for? And I said I've put in a request for higher level aid and attendance. She looks at this form. She said, okay, I think not for sure, but I think we have the right one this time. And so then we proceeded and I walked out of there. Three hours later I had a three hour CMP exam.

J Basser: 50:31

Anybody met her angry I?

Ray Cobb: 50:33

wonder who does that, I don't know. But, boy, I tell you what I really like the way she wrote it up. She nailed it, I think what she did.

J Basser: 50:47

She went up and looked up.

Ray Cobb: 50:50

she went up and looked up the 38 CFR code for R2, and the last two lines of it. She quoted it as if she was saying it herself and she might have changed one or two little words and I mean like his or, or, or, and you know but she used the exact same wordage that is used in the 38 CFR code, Right.

J Basser: 51:21

Okay, now you left me a question about do you do a lot of? Do you have a specialist that works in like in your organization that can actually do a lot of stuff like what do you call them gastroenterologists? Do you have one on staff or do you refer them out?

Bethanie Spangenberg: 51:47

That does what.

J Basser: 51:49

Gastroenterologists. They're the docs that do the scourge test and the piping. I'd say, Basically, they're plumbers.

Bethanie Spangenberg: 52:01

We don't. We don't get a lot of need for that, I think, as we expand, I think the next one we're going to add, our next specialist or area of expertise we're going to add, is a neurologist, because then that covers TBIs and more of the complex neuro issues. But we do not have a. Gi, in there I don't know that a need is there yet.

J Basser: 52:26

Right. Well, now, with the PACTAC coming out and all these stomach issues like that arising from the burn pits and stuff like that overseas, I'm sure it's going to expand in the future, so that's something to look forward to. You know, Kind of. You know, pay it forward, because that's one of the issues you know and that's bad stuff. I mean, expose this crap and take care of it.

Bethanie Spangenberg: 52:53

You know one thing we didn't talk about. We've got a few minutes left. Something we didn't talk about that I want to make sure we talk about is secondaries, and GERD is secondary, and things that GERD can aggravate or irritate. One of those things is if you have any type of lung disease or asthma, your GERD symptoms can irritate those your GERD can irritate or aggravate or even cause sleep apnea issues.

Bethanie Spangenberg: 53:30

Your mental health can cause GERD. Your medications, which we talked about, can cause GERD. So if you have a surface-connected back condition and they have you on three or four medications for that, it can cause some GERD issues.

J Basser: 53:46

So those are the big ones as far as secondaries go what type of limit on your fatigue, asthma or restricted lung disease or like that we're talking about?

Bethanie Spangenberg: 53:57

yeah, the, the GERD, the acid can cause some sensitivity in the lungs and make them more reactive to allergens. So if it's asthma, the allergens. If you have COPD, it can cause some issues where your COPD is not controlled and then more of the complex pulmonary diseases it can irritate as well.

J Basser: 54:20

Okay, well, that's good to know because I need to study that stuff. That's great, just more stuff to ponder. You keep me busy, you know that. Good, but, bethany, give us your contact information about the website and things like that so folks can get a hold of you if they need to contact you about maybe reaching out and getting an independent medical opinion or examination on certain issues and getting an independent medical opinion or examination on certain issues.

Bethanie Spangenberg: 54:54

So our website is wwwvalor4vetcom. You can also reach us by phone at 888-448-1011.

J Basser: 55:05

Okay, they'll answer the phone. She has veterans that will take care of you guys. She's got their own portal. You can upload your information and stuff like that. It's pretty, it's a painless process actually. I know some folks that used her and they seem to be pretty happy. So you know, I haven't had the opportunity to, but I haven't needed an IMO yet and hopefully I won't need one, but we'll see. But it's been a good show. Bethany, we discussed that stuff. Of course you're going to be back on here pretty soon. We're going to be talking about something else, a totally different subject.

Bethanie Spangenberg: 55:40

Yeah, we haven't figured that out just yet, but I'm thinking I want to leave medical again, talk about another DBQ and break down the rating schedule.

J Basser: 55:52

Well, you'd be welcome on that show and I might have to schedule a little extra time, but it's going to be a while For some of these.

Bethanie Spangenberg: 56:01

DBQs are long. Oh, you're right, some of them are like 12 pages.

J Basser: 56:05

Yes, so that's why you like Ray Cobb and get a three-hour C&P exam. Is that right, ray? I guess I thought she was just making sure she put it down the way it was supposed to be, and she did, and then she took time to read the question and read her answer to make sure that I approved of it, which I don't guess that was necessary, but it worked out. Our guest speaker used to be employed by the VA actually doing C&P exams. Betsy, can you testify Did?

Bethanie Spangenberg: 56:45

you ever receive the wrong DDQ or information about a claim? Yeah, I got the wrong. I actually had evidence tabbed in a claims file. This is back when we had paper files. I had evidence tabbed as evidence for the claim but it was the wrong veteran's MRI, so somebody else's name on the MRI. But it was evidence for that claim In the C-file.

J Basser: 57:11

All right, I know a veteran. I'm not going to name names because I don't want to say anything over the airwaves. I know a veteran that requested his C-files, his claims folder, from a certain regional office. I'm not going to say where it's at, but it's somewhere in the middle of the United States. He received his C-file and in that C-file was 511 pages of somebody else's C-file. He gets on the phone and calls the guy.

Ray Cobb: 57:47

I know who you're talking about.

J Basser: 57:52

And I know you're talking about that and that guy has become a very good friend to us and he lives somewhere down in Georgia and he's calling all the time. He lives so far in the hills he has to climb a tree to get cell reception. So we don't want to climb too many trees, but listen, we've got a minute and a half left. We appreciate you listening to the show. We always appreciate Debbie coming on. She's a breath of fresh air for the show and I get a lot of good feedback from her. They're in a group, they do a very good job and they're probably the most reasonable group for doing IMOs across the country group for doing IMOs, you know, across the country.

Ray Cobb: 58:31

And Ray.

J Basser: 58:32

I want to thank you for coming on and co-hosting.

Ray Cobb: 58:35

And we'll do it next week or so.

J Basser: 58:37

And yeah, we've got to do a makeup show here before the end of the month, so I figured it's a good day to do that, because we had some issues last week. But we do appreciate you, bethany. Thank you for coming on and keep doing what you do. Don't stop it. Don't stop doing what you do. And, on behalf of Gerald Cook, jay Basher and Mr Ray Cobb and Bethany Spangenberg, we'll be signing off. For now. You have been listening to the Exposed that 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.