Welcome, Hosts, and Guest Intro

J Basser 0:07

Welcome folks to another distance of Colette Productions weekly broadcast. My name is John. They call me Jay Bassers. Today is September the 4th, 2025. Can you believe it's September already? Today's co-host is the one and only Mr. Barry Freddy, down there in the close to Alabama, but he's still in Tennessee. How are you doing, Barry? I'm good. How are you, John? That's good. And today, in the uh first Thursday of the month, we've got Bethy Spangenberg on. She is going to discuss uh the issue of chronic fatigue syndrome. And she's got a whole setup for us, so she's going to discuss the DBQ and the legal factors involved. Bethy, how are you doing?

Bethanie Spangenberg 0:55

I'm doing great. I've been busy and had a little bit of technology troubles because it's not my thing, but here we are. I'm ready to go.

J Basser 1:05

Okay. Well, I'll turn this over to you. You go ahead and get started and get us get us in the right direction, anyway.

Bethy’s Background and VA Shift

Bethanie Spangenberg 1:12

So as John, you know, and Barry, you know, I am Valid for Vet. I am a former compensation and pension examiner. I'm a physician assistant. Medicine is my thing. I love it. Um, I fell into VA disability because my first job was at the VA. And when my husband was deployed, I didn't mind working like 60 hours a week in primary care. But when he came home, I didn't want that life anymore. So I transitioned to the specialty clinic where I was the only full-time compensation and pension examiner. And I learned a lot. I, from the very beginning, when things came off the printer or the request came from the regional office, I was the person that picked them up off the printer, read them, decided where they went, like what provider they went to. And so I was very heavily involved in that process and I learned a lot. And then Secretary Shinseki decided he was going to close all these two year old two-year or older claims out. And my husband fell into that. So here he got out in 2011. He had his disability compensation exam within a month of his discharge, and two years later, he got denied for everything that he applied for. So at that point, my passion transitioned into advocating for the veteran rather than being a great and great government employee. Because when I'm an employee, I try to be the best employee there is. And I really found that my value was elsewhere and not within the government system. So I say that to say that I've been in this a while now, since formally since 2015, as Valor for Vet or as the company, but we do a lot of disability claims. And chronic fatigue is one of those. We offer DBQs where the veteran can register and complete a DBQ. And what I am finding recently is

Symptom vs Syndrome: Defining Fatigue

Bethanie Spangenberg 3:15

a lot of confusion around chronic fatigue syndrome. We offer the DBQ for veterans who are seeking service connection for it. And I find that between me completing the questionnaire and what the what information the veteran provides, there's a big disconnect. And I feel like this has a lot of value for a lot of veterans, especially those that fall underneath the presumptive for chronic fatigue syndrome. Any questions before I dive in? Any comments before I dive in? Believe it or not, this DVQ is only five pages, but there's a lot of information that goes with it. So I want to first start with the medical understanding of chronic fatigue. When we look at fatigue, fatigue can fall into a symptom or a syndrome. Okay, and those are two very distinct definitions or words when it comes to chronic fatigue. So when I as a clinician think of chronic fatigue as a symptom, okay, that is a report that the patient is giving me. Okay, so they come into my clinic and they're saying, you know, I've been really fatigued, I've been really tired lately. And so that is something that I document in their history. It's not something I'm gonna say, oh, you have fatigue, chronic fatigue syndrome. It's not, it's not that way, it's a symptom. Um, similarly, we have other subjective symptoms such as pain, shortness of breath, nausea, or dizziness. And I provide those examples up there so that you can see, you know, what the symptom is. Like what, you know, I tell you that fatigue is a symptom, and so is pain. Pain is a symptom. These are things that I document, these are things that the patient is telling me. I put it into their charting system, and these are little things that I put together in formulating a diagnosis to understand what is going on with my patient. When it comes to syndrome, okay, this is different than symptom, but we are looking at a collection of symptoms or clinical signs, things that I find on exam, maybe some lab testing, but more data that consistently occurs together and characterize a condition. So this is where your chronic fatigue syndrome falls into. Okay. And if we look at it side by side, okay, look at symptom of fatigue versus chronic fatigue

VA Criteria and ICD Codes

Bethanie Spangenberg 6:10

syndrome. The duration of a symptom can be variable or short, short term. When those symptoms come together to make a syndrome, they typically persist for six months or more. Okay. The cause, a symptom of fatigue can be caused by a lot of diseases, sleep apnea, diabetes, heart failure, coronary artery disease. Those diseases can create a symptom of fatigue. In the rating schedule, we see fatigue captured in Met's testing for coronary artery disease. So when the examiner is asking if the veteran gets short of breath or has chest pain with mowing the lawn, push mowing the lawn, sitting watching TV, all those scenarios are put together or all those symptoms are put together to capture the fatigue for the rating schedule. Okay, so that's a symptom. Now, when we look at the cause of fatigue, it is unexplained after we've ruled out every other possible disease. The symptom of fatigue often improves with sleep. Maybe that individual's not getting enough sleep, they get you know a few good nights of rest and quality nights, and that fatigue may get better. For chronic fatigue syndrome, it does not approve in Peruve, no matter how much sleep they get. Post-exertional weakness. So if they go and they decide that they're going to load the dishwasher or try to do something productive because they're wanting to be active. For this symptom of fatigue, they have some of it. They do experience some of that post-exertional tiredness or fatigue. For chronic fatigue syndrome, it is persistent, it is a hallmark sign. Fatigue. Fatigue can mess with your your your thought process. If you've ever gone a long night where you haven't got much rest, you can experience, you know, where your words jumble, or you say something you didn't mean to say, or you stutter, or you may have troubles, you know, getting your thoughts out there. And it's temporary. For chronic fatigue syndrome, it's usually a persistent impaired thought process. When it comes to function with fatigue symptom, you uh have slow activity, but it's manageable. So you know, like, oh my fatigue is worse in the afternoon, so I do X, Y, and Z in order to get what I need done. For chronic fatigue syndrome, there's a significant reduction in your daily activity. So it doesn't matter what time of the day that you're trying to get the dishes done, it's it's going to be bothersome or troublesome any time of the day. Again, sleep, we kind of talked about this already, improves the sleep, does not, um, or chronic fatigue syndrome, you often have non-restorative sleep. This is important when it comes to the, and this is this is why I wanted to do this presentation. We preach in this show a lot about having a diagnosis,

Exclusions, Testing, and Timelines

Bethanie Spangenberg 9:45

okay. But you can't just have any diagnosis, you have to have the diagnosis for chronic fatigue syndrome. So if you look here at the bottom, for the symptom of fatigue, the medical clinician, the medical examiner, may put in a medical ICD code. Okay, that is for insurance billing purposes. That is not a VA legal code, that is a billing code for insurance purposes and for Medicaid and Medicare, things like that. So when the clinician types in other fatigue, and it's a code R53.83, that is a symptom. That is not a that is not a syndrome, that is a symptom. They may put in other malaise and fatigue because it pops up quicker in their charting system when they type in fatigue that that may pop up first. So like eh, they stick it in there and they don't care. It's billing code, it's for insurance purposes, their clinical documents supports their um their diagnosis of a symptom, right? That is not these two codes are not the same as chronic fatigue syndrome. Chronic fatigue syndrome is a set of criteria that has to be met. And when they meet that criteria, they get the R, actually, this is supposed to be G, it's supposed to be G93.32. And we'll see that pop up correctly later in the in the thing. I must have fat-fingered that one, but that's a G code. And that is important. So if you're a veteran seeking benefits for chronic fatigue syndrome, you're looking at getting a medical opinion, you need to make sure that that G93.32 code is in your medical record. Okay, it needs to say chronic fatigue syndrome, and I will show you why that's important. This is the rating schedule for chronic fatigue syndrome. This is something that the VA has posted in their their schedule, their rating schedule, and it defines exactly what they expect from chronic fatigue. Now, what's also important to know about this definition is it's a 1994 Center of Disease Control definition of chronic fatigue. So we are using this definition that is not up to date, where medicine has changed over the years. This is not how we look at chronic fatigue today. Okay. Good news is I will tell you that if you get a diagnosis of chronic fatigue today, majority of these uh facets or these points are here. So you shouldn't have to worry about meeting the criteria for the VA. Okay. Um, so the criteria, I'll briefly read it just because I think it's important to hear it. For VA purposes, the diagnosis of chronic fatigue syndrome requires one, a new onset of debilitating fatigue, severe enough to reduce daily activity to less than 50% of the usual level for at least six months. And the exclusion by history, physical examination, and laboratory test of all other clinical conditions that may produce similar symptoms. And six or more of the following acute onset of the condition,

When to File vs When to Diagnose

Bethanie Spangenberg 13:10

low grade fever, non-exudative pharyngitis, so that means that you have an irritated throat without like pus or drainage, palpable or tender cervical or axillary lymph nodes, that's lymph nodes in your neck and under your armpit, generalized muscle aches or weakness, fatigue lasting 24 hours or longer after exercise, headaches, migratory joint pains, neuropsychologic symptoms, those are those cognitive symptoms we were talking about, the thought process kind of kind of deal, and then sleep disturbances. The reason why I think it's so important to hear that is if you look at the bullet point two, a lot of veterans miss the exclusion by history, physical examination, and laboratory tests of all other clinical conditions that may produce similar symptoms. That is so important for chronic fatigue syndrome, both legally and in the clinic. In the clinic, if we are trying to investigate someone's complaint of fatigue, there is a laundry list of testing that needs to be done. That testing is not available to a CNP examiner. You are not going to get a C and P examiner to order all the tests that are necessary to give you a diagnosis of chronic fatigue. The other part is you may have had these tests, but sometimes they're done in 2016. And then in 2018, you may have one or two tests, and then 2021, you have another test. And so here we have a five-year gap of all this testing, and none of it is really capturing this new onset, this new symptom, this new complaint, or it's not capturing when you said that you were developing this. So if you're trying to say that for your claim that you started to have fatigue symptoms in 1996, and we have absolutely no workup for it, we see we have a diagnosis, but we have no workup, then you may have to start from from scratch and start over and capture all those tests in order to support that diagnosis and that claim. Any questions there?

Beri 15:29

If you have those tests run, I mean, how close together would all because you know if you go to the doctor, they're going to try to eliminate one thing at a time. So does all those tests need to be within like a six-month period?

Bethanie Spangenberg 15:42

Well, it may take you six months to get those tests.

Beri 15:46

I was gonna say because if you start scheduling one, that's that's a year's worth of tests, don't you?

Bethanie Spangenberg 15:51

It really is. Um, especially through the VA system because of how frustrating their obstacles are to even get some of these tests. Um yeah, it's typically more than six months to even get these tests done. So and I actually have a bullet point on here to talk about that later, about um how we preach, you know, don't file a claim unless you have a diagnosis. Well, in this case, it may take you forever to get a diagnosis. So you you kind of want to put the the horse before the cart on this one.

Beri 16:25

Well, you know, and that's like Alex says a lot of times, you know, you you if you, you know, for example, I've got CITER, you really would have to go do your own C and

Fatigue as Residuals and Pyramiding

Beri 16:35

Ps and get all that knocked out on your own, really. Yeah.

J Basser 16:46

You know, if you want to claim it and uh you know you have it, then uh let somebody uh let a good examiner look over the results and uh give an opinion as to their opinion, and uh maybe call you up and do a video opinion or whatever, like uh IME, which is independent medical examination, and uh you know person to call to do it, send them a little bit of salad and you're ready to go.

Bethanie Spangenberg 17:13

That's exactly it. So for this next slide, um, you know, I want to talk about why, you know, I've talked a lot about why it's important, but I kind of want to dig a little bit more into it. Um let's see, I'm looking at my notes here. We've already talked about the oh, this is where we talk about the formal diagnosis. Oh my gosh. Okay, so 99% of the time, I typically recommend that you have a formal diagnosis before you file your claim. Only because of my experience as a CMP examiner and what I have experienced over the last 15 years of watching veterans get denied. It is my role as a medical expert with my understanding to preach to veterans and advocates what I think will be in the best interest of the veteran majority of the time. Do I understand that there are cases where they don't need a diagnosis? Absolutely. Are there cases where they should file the claim and then chase the diagnosis? Absolutely. But from everything that I've experienced, my passion is veterans do yourself a favor, go get the diagnosis. Don't allow your money to sit with somebody else who is going to represent you when you can be doing the work yourself. And half the battle is getting that diagnosis. So that is why I I preach that. And that's why I've kind of that's been my soapbox. And um, but I do understand and I appreciate that that's not the case for for everything. And this is one of them that that can be, you know, where where it's kind of you know, put the put the horse before the cart kind of thing. And whether it's the intent to file, whether you file the fatigue, and then you get the workup. But um the reason why, let me look at my notes here. The DVQ that we complete, the the hurdle that I see is that the veterans are wanting me to click that they have a chronic fatigue syndrome diagnosis when it is not documented in the chart. And I cannot do that. They may have uh sleep apnea with hypersondolence documented in the chart, they may have COPD documented in the chart, they may have asthma, those are not diagnoses for chronic fatigue syndrome. The other part is as the medical examiner specifically related to chronic fatigue syndrome or chronic fatigue symptoms, either one, whatever you're claiming, I cannot be that legal person for you. So if you tell me that you're filing for chronic fatigue symptoms related to your cancer, then

Case Study: Cancer, Treatment, and Ratings

Bethanie Spangenberg 20:20

my job is to document in the DBQ your symptoms, your testing results, um, your limitations in employment. It is not my job to say, oh no, no, no, you should be filing for chronic fatigue syndrome versus the chronic fatigue symptoms. And veterans get very lost in what they're filing and what their goals are. Let me give this other example so you can kind of follow the difference. A disability is anything that can impair functional employment or functional gain or functional limitations, um, there's a definition for that. Look it up. But fatigue can fall into that category, just like pain. That's where that case, like 10 years ago, came out, and they're like, oh, pain can be a disability now, pain can be a disability now, I'm gonna file for chronic pain. That is similar in this scenario when it comes to fatigue. So if we look at the claim or the treatment for chronic lymphocytic leukemia or even CML, if your cancer is active and you're undergoing treatment, then you're 100%, you're supposed to be 100%. Well, we've had cases where because their cancer is now controlled, but they're on active chemotherapy, the VA is proposing to reduce their benefits. So another alternate route is say, okay, okay, you're gonna say that this veteran no longer has active cancer, active treatment, but then you need to rate him for his residuals. And one of those residuals is his fatigue, and his symptom of fatigue puts him at 100% disability. So either way, the VA wants to spin it, you still owe this veteran and this man a hundred percent disability. So that is one tool that you can use. Is it always successful? No. But it's still an avenue for the veteran to advocate for their percentage and their disability if they're going to try to say, well, your cancer is controlled with your treatment. I've I've had a veteran, John, I've talked to you about this veteran. This veteran has had active cancer since 2016. He's still an active treatment. He takes medicine every day. That medicine makes him so sick. Part of that 100% disability rating is understood that active cancer under active treatment with a anti-neoplastic chemotherapy per rating schedule is disabling to the 100% degree level. And that incorporates the side effects of the disease, the side effects of the medication, the disability that it that it causes that individual. That 100% is incorporated or encaptures all those limitations that that cancer, that act of cancer causes. So for this particular veteran, we did the DBQ and we showed the DBQ is causing disabling fatigue, and he's warranted 100%. Now that is before the VA, and the VA has to decide how are they going to rate this individual. So we have all the evidence on the table that this individual will get 100% for his CLL or his cancer. The VA won't give him both. The VA won't give him both fatigue and the 100% for CLL because that would be pyramiding. But in this scenario, he's filing for fatigue as a symptom of his cancer without having a chronic fatigue syndrome diagnosis. Are you following me on that? Any questions about that?

Mental Health Factors and System Hurdles

J Basser 24:30

I just think what they're doing is kind of criminal themselves. Um it's like I don't understand, but they do understand, and it's just it's just a waiting amount. I think uh a lot of times they'll get a sick patient like that that's really sick, and they'll wait about until they kick the bucket.

Bethanie Spangenberg 24:50

Well, you know, I've tried to talk to this veteran. This veteran is very worried about his benefits because it's not just him, but it's his wife, and he's worried about caring for his wife. And as much as I say, you know, like hold your horses, like I don't know what my deal is with the horse and the all these horse preferences today, but okay. Um I said just hold your horses, let's wait till this date. Once this date hits, then we're gonna start to get our ducks in a row financially on your end, because you know, I don't know what the VA is gonna do. But you know what I think he did, and he he won't admit it, but I think he stopped his chemotherapy because this last month he had abnormal labs and hit it shows that his cancer is active, like the medicine's not suppressing it. So I think that in all of this chaos that the VA has has caused him and all the stress that has caused him, he's like, you know what? I'm just not taking it anymore. And so just that quickly, within a matter of three to four weeks, he stopped taking that anti-neoplastic chemotherapy and his his leukemia numbers are are back up. So then again, there's evidence that he has active cancer, but I mean, it's ridiculous that veterans have to sacrifice their own health in order to get what they're legally entitled to and what's in front of the VA.

J Basser 26:14

They're conducted for mental health.

Bethanie Spangenberg 26:16

No, he's not, but I'm I'm really that should be a secondary. Yeah.

J Basser 26:24

Because it tells me that he's affected by that and he could take him to his chemo because the VA keeps denying him or whatever it is, then that needs to be added addressed too.

Bethanie Spangenberg 26:33

Well, they came out and they did a couple wellness checks on him because he's uh threatened, you know, self-harm. Um which I'm not in his position, but from what you know what I've seen him like through the medical record part of it, you know, since 2016, he's been through a lot. I mean he's lucky to even be here.

J Basser 26:53

So help we can get, but I mean it's gonna help veterans get better, guys, and they've got cancer or some kind of disease that can be cured. You know, the best thing to do is make sure that you know that if service connected issue, which it should be, they need to go ahead and do it. Instead of waiting around and playing games. It's all a big game to them.

Gulf War Links and Unknown Exposures

J Basser 27:21

I'm sad that's true, you know, it's a game. And the BDA is the reason that that's the end point of the game, is going to the Board of Vegetable Pills. Because they're playing games.

Bethanie Spangenberg 27:37

So I guess the takeaway for this here is to understand, you know, my role as a medical examiner is not to say you have chronic fatigue or to say that you have a qualifying condition for a claim. It's my role to document your symptoms, your treatment, what the testing shows. And so when you come to me for a DBQ and you kind of don't know what you're doing, you you may want to talk to a representative before you dive in and go the wrong direction because I I really can't help you on that. Um when I do sit down to do the chronic fatigue DBQ, the first thing that I look for is I look for that G code. Let's see if it's gonna let me click this. So I look for that G code, it's G93.32. Earlier I had it as an R, but it is a G93.32. And I look for it because that tells me, yes, they have the diagnosis, and this is what my focus is going to be for this DBQ when I write this history and the testing results. I want to emphasize that in the physical DBQ, it also has listed at the top of page two the criteria that needs to be met. So the veteran, again, needs to understand this is the criteria that they need to meet for the VA's 1994 definition of chronic fatigue syndrome. So, what does it mean when chronic fatigue syndrome is an unexplained cause after rolling out other causes? Or unlike we really can't find out the cause of why they're having these chronic fatigue issues. What we call that in the medical world is we call it a diagnosis of exclusion. Okay, so basically, we are going to make the diagnosis of chronic fatigue syndrome after we've investigated everything else. So it's by process of elimination that you don't have all these other conditions, and so it must be chronic fatigue. Syndrome. When we work up chronic fatigue syndrome, it is a lot of labs. We are going to look for your blood count, your kidney function, your liver function, your thyroid function, your blood sugar, your blood sugar over 90 days. We're going to look at your iron level, your vitamin B, your vitamin D. We're going to look at inflammatory markers. We're going to look at autoimmune markers. We're going to look at all these different viral panels. There is a ton of lab work that is tied to this. Luckily, most of those labs can be captured in one setting. You don't have to make several trips for it, but there's going to be a lot there. There's a lot of work, workup that comes with that complaint of fatigue. Sleep evaluation. Especially now, sleep apnea, that's going to be at the top of our list. You're telling me you have chronic fatigue. I'm going to go ahead and order you a sleep study. If you meet, you know, even if they don't meet risk risk factors, if they're telling me they have fatigue, they should really have a sleep study anyway. Because you can have central sleep issues where your brain's not telling your body to sleep well, or it's malfunctioning centrally in the brain

DBQ Walkthrough and Evidence Needs

Bethanie Spangenberg 31:10

to not hit those sleep cycles. In addition to the obstructive sleep apnea, you're going to have an EKG, maybe an ultrasound of your heart, a chest x-ray. We're going to look at your heart and lungs and make sure they're functioning appropriately and they're not causing some form of fatigue. Sometimes, if there's indications there, we may refer you for a mental health evaluation. A lot of times, especially with depression or, you know, some of the downer type mental health issues, they can cause fatigue, or you can actually have the flip. You can even have ADHD where you're spinning all the time and you end up crashing and having fatigue as well. So that's part of some cases, it's it's mental health is part of that workup of chronic fatigue. Any questions about that? I think Barry, that was one of the questions that you kind of were leaning into.

Beri 32:06

Well, and you know, it's interesting, all those symptoms that you listed. I was thinking about if you've ever been on a long deployment, you know, for after two or three months of most fleet, you have all those symptoms, but they go away eventually with the rest. So it was just it's very interesting reading that list and thinking that's how you feel if you're really exhausted over a few months period of time.

Bethanie Spangenberg 32:33

Yeah. I think that's why they set that limitation on there for the six months, is because um because of things like that, especially with the military. The the other component, other thing that they're finding, is there it's kind of like were you were you do you understand the timeline of like hepatitis B and when that came around?

Beri 32:57

Yes, yes.

Bethanie Spangenberg 32:59

So we really didn't know what it was when it first came about, right? And so they called it um, was it non-hepatitis something or other or something, I can't remember what they called it, to be honest.

Beri 33:13

They had another name for it, yeah.

Bethanie Spangenberg 33:15

Um, yeah, they had another name for it, but that was in the nine uh the eighties or nineties. Now I'm missing my timeline, but you know, we didn't know what it was, so we called it something. Okay, we gave it a name and we held on to that name for a while until we really couldn't do the science behind it. They're finding that a lot of our military members, and that's why they've the tag the Southeast Um Asia, the Gulf War veterans, they're finding because there's different bugs and bacteria and viruses in those countries, that they are catching them, and there it's it ends up causing a lot of these unknown symptoms. So maybe in 10, 20, 30 years from now, we're gonna say, oh, well, that's that that disease now. We didn't know what it was 30 years ago, but now we know what it is. And so I see this Gulf War syndrome following the same pattern of the the hepatitis pattern.

J Basser 34:10

Um I think any questions about that, guys. Probably better. I mean, we can ask Alex. He read it firsthand, and um so we've got a cure for that now, supposedly. Which is good and uh he's got there's more than just hepatitis involved with that. You're looking at uh porfuria and all kind of crazy stuff, yeah. So uh I mean I've had him on the in the past for shows and we discussed every issue, and it's known to the son, and he's had it.

Bethanie Spangenberg 34:49

So and now that you mention that, it's hepatitis C, and they used to call it non-A, non-B hepatitis. Yep. And so,

Ratings, Restrictions, and Functional Impact

Bethanie Spangenberg 35:00

and and we didn't know, you know, that it was even like a bloodborne pathogen. So these air gun injectors that we were given to our veterans, that's how some of them got hepatitis C. And you know, there is a there was a study out of California in the 90s that actually like threw those air gun injectors in the trash because they tied an outbreak of hepatitis C to those air gun injectors in California in the early 90s, and so that is a lot of the research that we use when we talk about hepatitis C.

J Basser 35:35

So 20 years ago, back when I was doing the moderation for uh the Hadit site, we had a guy named Alan, and uh he was a bowl tech in the Navy and a real nice guy, and he contracted different stuff and he blamed everything on those jet guns. And he filed and filed and filed and did this and that, and they denied him every time he went in. Because the you know, the jet guns didn't cause that, you know, but we knew it did, but I mean there's nothing we could do about it, and I don't know what happened if he got it to the board or what, but uh I don't know if he was still with us or not, he disappeared off the side. We're sad.

Bethanie Spangenberg 36:18

Another thing since I we're talking a little bit about Gulf War, uh this is this is totally off topic, but it's just triggers and something actually comes up quite a bit in my memory. But several years ago, I had um a patient come in and I was doing a work assessment on him, and he had a history of some type of foot issue that that mangled his foot, and you could see all the the tendons in his foot. He had very little fat, lots of scarring on his foot. And part of like the work evaluation is I need to understand, you know, what he can physically do. And so in obtaining his history for that foot injury, it was the craziest thing, and I it stuck with me obviously this long. But what happened when he was younger? His brother was deployed overseas somewhere in the desert. And when he came home, he was supposed to like get rid of his boots, decommission his boots, get rid of everything. But instead, he gave them to his his brother, this patient in front of me. So this patient in front of me had these military boots on, and while he had his military boots on, he was working in them and he stepped on a nail, and that nail went through the shoe, through the bottom of the shoe, and to his foot and punctured his foot. And he ended up almost losing his foot because infection control, they had all these specialists, could not figure out the type of bacteria that was in his foot. And here it was because

Secondary Claims, Sleep Apnea, and Errors

Bethanie Spangenberg 38:00

those boots that he wore that his brother had overseas carried a much like a foreign bacteria to us in the states. And so they had to do a lot of work to figure out what antibiotics to use, how to treat this bug because of the different bugs. And I say that because that tells me that that's probably where this Gulf War syndrome is going. Knowing the history of the non-N, non-B hepatitis, seeing this these foreign bugs coming over and affecting our but uh just our population here, and even the veterans here, we don't know what they're carrying. Why are so many uh of these Gulf War veterans, why are so many of them having sleep apnea when they don't have all the risk factors? Why are they having all these different symptoms, these chronic fatigue syndromes, these undiagnosed illnesses? What is it? We haven't figured it out, and we I think we will, but that's one of those things that you know I'm foretelling the future. But anyways, that's a lot. I'm gonna get back to the presentation. Okay. Um I've already talked about all that, so let's go on to the next one. By the way, this guy is an angry VA compensation a pension worker, just so you know. He's he's not part of our team at Ballot for Bet. He's just the angry guy at the VA. Um, so now I just want to go over the DBQ. This is what we've all been waiting for. Um, five pages. Uh this can actually be done over the phone as long as you have the proper paperwork, the proper testing. All those tests that you get for the workup of your chronic fatigue syndrome, I want them. I want them when I'm completing this DBQ. This DBQ takes me about 45 minutes to an hour because a lot of it is reviewing the medical record. I have to literally copy and paste what is in your record, was it what is important to support that diagnosis of chronic fatigue and dates and types of images and things like that, types of lab work. Um, I have to carry that or put that all into this chronic fatigue syndrome DBQ. Um, the DBQ itself, like I said, it's five pages, very simple. It specifically asks for the criteria of meeting the chronic fatigue diagnosis. So um, question two C have other clinical conditions that may produce similar symptoms been excluded by history, physical examination, andor laboratory test to the extent possible? If a veteran does not provide me their workup, I have to say no. And so they they may reject this DBQ

Gulf War Presumptive Pathway

Bethanie Spangenberg 41:00

and say, well, they don't meet the criteria for chronic fatigue syndrome. But if the veteran is looking at chronic fatigue as a symptom, then that would be fine. It asks about the onset was the chronic fatigue sudden or did it happen gradually? Is it debilitating? Um, they define the incapacitation as um a requirement of bed rest for from the physician, from the treating physician. They ask specifically about the symptoms, if they're constant or if they come and go, and how they restrict routine daily activity. For example, if the symptoms due to chronic fatigue syndrome are nearly constant, do they restrict routine daily activities as compared to the pre-illness level? And then it goes through, and you're supposed to say it restricts routine daily activities almost completely when compared to pre-illness level. And in fact, that it precludes self-care. They're not able to do their ADLs or care for themselves. Um daily activities to less than 50% of the pre-illness level. Symptoms restrict daily activities from 50 to 75 percent of the pre-illness level. Symptoms restrict routine daily activities by less than 25% of pre-illness level. Those are confusing. I read them out to you just so that you can understand the criteria. That is the rating criteria that they're asking in those little check boxes. Okay. The most important part, go ahead. The most important part I feel that is in this DBQ, aside from having your testing to support the diagnosis, um, is the functional impact. When I do these DBQs, I want to hear an example, a real-world example in your life, how this chronic fatigue has impacted you, your work, your social life, all of it, so that I can emphasize that to the VA. I will, you know, put it back into the DVQ and emphasize just how, from an occupational health standpoint, how these chronic fatigue symptoms or syndromes can affect this individual's functional employment or functional gain. So there's not really anything fancy or confusing to talk about there on the DBQ. Any questions about the DBQ itself?

J Basser 43:49

Is that mainly a Gulf War thing?

Bethanie Spangenberg 43:53

Right now, yes. Um, I see a lot of veterans trying to do fatigue secondary to like sleep apnea, and they're not gonna they're not gonna get fatigue symptoms, secondary sleep apnea. Now,

Closing Notes and Next Guest

Bethanie Spangenberg 44:10

if they go on to develop the criteria for chronic fatigue syndrome, then they may be because of the separate diagnosis, they may be able to get it. Um, but again, for like sleep apnea, that fatigue is incorporated in the rating criteria already. So I see a lot of errors in how veterans are pursuing the chronic fatigue or chronic fatigue syndrome, and so that's why I want to.

J Basser 44:40

You hear that people. Sleep apnea. If you have daytime tiredness, it's called an insolvent or whatever it is, and it's part of the sentiment of sleep apnea or hyper what do you call it?

Bethanie Spangenberg 44:52

Hypersonnolence.

J Basser 44:54

Yeah, well, if I have a teeth, I could say that word. It's always best to get the best information you can and uh have it explained, you know, in terms of people can understand it, and uh that's good. I'm glad you did this. That's good.

Bethanie Spangenberg 45:14

So I've only got a few more slides here. I just want to uh list specifically the rating criteria. I'm not gonna read it off. I'm just gonna make make an emphasis about the rating criteria because it's in the slides. If somebody's watching YouTube, they can hit pause and they can read through it. Um here for 40, 20, and 10% rating. Okay. And there's a few other important things. Uh, we already talked about pyramiding. You have to watch for pyramiding. You could be spinning your wheels and they come back and say, No, you're pyramiding. So if you're thinking about filing for for chronic fatigue, secondary to something, you need to sit down with the VSO, unaccredited agent, uh, talk to somebody that has that can kind of explain the pyramiding to you and how it applies to your disability. Um I've already given the example of the cancer where uh despite the fact that the individual is active treatment, active cancer, they're trying to give him a zero percent because it's it's normal, his labs are normal. Um, you know, that's that's one fancy creative way that we're trying to push to keep that 100%. It's like fine, if you're gonna be a jerk, then you know, rate him on his residuals. What's his residuals?

J Basser 46:43

Exactly. Does the regulation state that I'm sorry, that if the cancer numbers are showing different, but the cancer is still active, does it put the difference or does it just say uh still active process?

Bethanie Spangenberg 47:02

So there's a a we call it a race aging, and so they're like, oh, but if the race zero, then it's normal. Ray zero has to do with the progression of the disease, not necessarily the treatment or whether it's active. So to try to erase the fact that the cancer is active and that he's on active antineoplastic chemotherapy for the treatment of the condition is is an ignorant way of trying to say he's fine. Um, the last thing I want to emphasize that are important is just that Gulf War presumptive. And I just want to lay this out there on the criteria that are needed for the Gulf War presumptive. So chronic fatigue syndrome is listed as a presumptive service connection if the following conditions are met. Their service occurred in Southwest Asia Theater of Operations. Their symptoms began during service or became compensable by greater than or equal to 10% within the next year. And we're looking at 2026. So if sometime in the next year you start to develop these chronic fatigue syndrome symptoms to a 10% degree, you're still eligible as a Gulf War presumptive. And I oh it's signs and symptoms cannot be attributed to any known clinical diagnosis through history eczema lab, which that's the criteria that is chronic fatigue anyway. But here is that 10% that you're trying to meet as a Gulf War presumptive.

J Basser 48:38

That's very similar to hypertension, 10% presumptive test. It's gotta be compensable, right?

Bethanie Spangenberg 48:50

And that's all I've got for for the deep chronic fatigue syndrome, do you think you're good.

J Basser 49:03

Pretty good, didn't have to rush, took the time. Last time we had to get through it in a hurry.

Bethanie Spangenberg 49:09

Well, it was the back one was like 11 pages.

J Basser 49:13

It was huge.

Bethanie Spangenberg 49:14

Yeah.

J Basser 49:16

It was huge, it was big. I don't know. I don't want what do we have left to do on these DVQs? I mean, uh, we covered the back, the neck, the nerves, the spine.

Bethanie Spangenberg 49:28

Believe it or not, we've been doing this for like two years, and we're still not done. There's like 76 DVQs. I'm just trying to hit the top ones. We'll get to the the smaller ones eventually.

Beri 49:42

Yeah, that uh pretty interesting. You were talking about I've known a two cases of people came back from uh OIF. I think they were both OIF. And uh they had a family member that got ill or got a skin condition from maybe washing their uniforms or being exposed. And like you were talking about that boot, I mean, because there's some bad stuff. You you're in a country that still has the plague, and uh you don't really know what, you know, but I've and it it's strange that and you you can't get it clean over there before you come home for the job, and it's not clung.

J Basser 50:23

Have you guys ever come across you ever come across any Korean war vets? A good friend of mine was stationed over in the DMZ. He was in a guard, but he got activated and went over, and uh he's a command sergeant major. And he got lucky because he had his own people to do his laundry and stuff, you know, and they did it, did it right. But the actual active troops, they would spray those uniforms down with some kind of insecticide with deep in it because of all the mosquitoes and bugs over there. And majority of them got really sick in bad shape because of the chemicals they used spraying the uniforms.

Beri 51:05

That bug juice.

J Basser 51:06

You ever heard of it?

Beri 51:08

Go ahead. I don't know, but I had some of that that ate the case in off my watch one time, so I quit using that old stuff. If it'll eat the case in your watch, what's it doing to you? Yeah, no, I had a G Shop place in it, so I threw that away. The time X G Shark or the Casio? It was the Casio G shark G Shop, and it ate the case up, you know.

J Basser 51:32

Whoa. That's pretty sad. That's just lead acid. So if it kills bugs and mosquitoes, is it gonna kill you? You get enough of it to kill you too, because you're or you're you're an organism or organic material just like they are. No, but yeah. But Korean bests are few and far between. You know, and uh that'll be well.

Beri 51:59

Yeah, I think we're down like 43% Vietnam best left.

J Basser 52:04

So if he'd have chosen to, you could actually cover two. You know, if you've got two small ones, we could probably split it up and do one first part of the show and another second part of the show.

unknown 52:14

Okay.

Bethanie Spangenberg 52:15

I'll take a look. I thought I had uh wrote one down that I wanted to do next. I don't know. I I try to I was gonna try to do it in order, but now I'm just doing it into what annoys me. So not necessarily what annoys me, but what's like, hey, you know what? They there needs to be more clarification on this one. So um so that's that's what I've been the game I've been playing lately. Okay.

J Basser 52:43

Well, I do appreciate everybody coming on. Barry, thank you again. I'm glad you made it back from Ohio and in good spirits and in one piece.

Beri 52:53

Well, I am too. I it was uh you know, that's the first real work I've done in a while now. My wife's had me in there two weekends. So I'm back to it. She's gonna start slapping honeydews on the fridge again.

Bethanie Spangenberg 53:08

Yeah.

Beri 53:09

You know, the thing is, you know, I work, you know, I work for and I get usually get fired about once a month, but then I have to show back up at work the next day. I don't get it.

J Basser 53:21

You say you're the CEO, you can't fire yourself, and you don't have a board of director. You got one board of director, and that's the wire.

Beri 53:30

That's it.

J Basser 53:31

Yeah. Oh you're the same situation, but you can't fire yourself either. My wife is fireing me in a moment.

Beri 53:40

She's great though. You know, I keep complaining. Got a really great fringe benefits packaging up.

J Basser 53:49

We're gonna shut her down. I've uh has made the dental work done and I've been pretty serious pain all day, but uh figure I took this one out. So uh with that, busy, thanks for coming on. Ray, thanks for I mean, Ray. I'm sorry, Barry. Uh had rail on my mind. Thanks for coming on, we appreciate it. We'll we'll do this again next week, guys. We're gonna have a new guest on. She's a uh credit appeal. No, she's an attorney out of Washington, D.C. I'm sorry. Um I'll advertise the show up this weekend and get out there, and uh she's really good at what she does. She's got her own office and she does ethnic things out there in Virginia. So uh this will be John on behalf of Bethany and Barry, we'll be shutting her down for now.