We’re here today to try and inform as many veterans as we can.

We’re here with Dr. Bash.

Welcome, radio land, TV land, and YouTube viewers and listeners. This is Dr. Craig Bash. I’ve been doing Veterans Medical Opinions for 30 years, and I have dozens and dozens of these radio shows, which we’re going to publish on this YouTube channel, numbered one to whatever. So thank you for listening, and here we go.

Okay, we’ve already set the discussion topic. We’re going to start off with the Bash Bulletin, one that deals with the importance of getting independent medical opinions or examinations when doing your VA claim. Right, right, for the examination. Yeah, yeah, I mean, you know, a specific question, basically just kind of an overview, you know, just based on your bulletin itself. You know, how you roll it up, just basically the importance of getting an evaluation, what to look for, and things like that, and what type of evaluation a person needs, and you know, what type of doctors and things like that, just general information. Yeah, yeah, you know, those CMP examinations or DBQs are important because it’s the way the VA provides Nexus. You know, the DBQ and the exam are basically the rating percent, and the Nexus is the linkage.

So, the VA can hurt you on both sides of that. They can downplay the exam, and they can downplay the Nexus. So the best idea is to be prepared when you go in, and one way to be prepared is to make sure you get as much testing as you can. So, for example, maybe you have a spine injury, and it’s gotten worse over the years. If you get a repeat X-ray or MRI scan that shows it got worse, then that’s good evidence the VA has to think about, instead of just relying on a physical exam that might be a little bit better depending on the day and stuff like that. So that helps. That applies to kidney disease, hearing tests, and everything. Try to get testing to document what’s going on.

Then, I always talk about trying to find out who the examiner is. Sometimes they have nurse practitioners and PAs, and those guys oftentimes don’t have the depth of knowledge. You know, I had a patient last week who had all kinds of problems. She had some weight loss, some arrhythmias, and then lo and behold, she had a bunch of hair loss in service. Later on, she ended up with thyroid disease, and when you put it all together, she had thyroid disease back in service. That was all part of that hair loss problem she had. You know, nurse practitioners and PAs aren’t able to deal with all those different complicated aspects of the medical part, so they just take a little piece of it. You know, the VA says, look at the person’s spine or just their hair loss or something. It’s kind of like the old story with the elephant. Somebody feels the trunk, somebody feels the tail, and somebody feels the side of the elephant. They don’t realize it’s an elephant until they put it all together. Also, it’s a little puzzle. That’s why I like medicine diagnosis; it’s a puzzle.

So then, you’ve got to make sure you have good lay letters. Get those done first. I always recommend getting an IME, you know, a Nexus letter. Get yourself a Nexus letter before you go to the exam. At the exam, they won’t let you enter new evidence. You want to make sure you get that stuff uploaded a few days before so that the examiner has to read it and has a chance to look at it. If they don’t look at it or integrate it, that’s an automatic appealable thing because it’s an error not considering all the evidence.

Let me repeat, patients, Dr. Bash mentioned the term IME, folks. That’s a very important term. I mean, you’ve got an IMO, which is an independent medical opinion, but an IME is an independent medical examination, and that’s kind of a little higher level. The VA takes a little more weight to that examination versus an opinion. So that’s a good point, Dr. Bash.

Yeah, IME is a big deal. I had a guy who had like five issues, and the VA only did one IME on that personal DBQ. So I wrote my DBQs, and sometimes they take them, sometimes they don’t. But when I do a DBQ, that forces the VA to do some DBQs on their side. So they had to go back and examine him for the four or five leftover issues, and then we can compare notes and stuff like that. So yeah, those IMEs are important. You know, the X-ray is kind of an IME, and the lab tests are kind of an IME, because all those data points match up to help the claim get rated.

Yeah, also I tell patients to think about the worst-case scenario, which is really the idea of a flare-up. The VA has a lot of rules about flare-ups, and so the examiner is supposed to talk to you about flare-ups. A lot of patients are stoic; they don’t want to talk about it. They take pain meds before. I tell them, don’t take your pain meds. Also, make sure you talk about the worst-case day with the flare-ups so the examiner has a chance to do it. Sometimes examiners will give you leading questions like, do you feel great today, or do you feel normal? The patient says, yeah, I feel great or whatever, and the examiner writes down normal, when really the patient might have chronic pain. So that’s important. Also, I tell them to make sure for the exam they take their crutches, wheelchair, cane, or braces, any of that stuff, because often times if the VA exam might spend 10 or 15 minutes, and if there’s no crutch, cane, or wheelchair, they’re not going to mark any of this stuff down. So yeah, make sure you use all those devices.

I know we had a guy here that was somewhere in one of the VA systems going in for a CMP exam. He got his cane out of his car and struggled into the VA, went through his exam, came back out to the parking garage, popped his trunk, and put the cane in there and got in his car and walked off like nothing was wrong with him. They used that against him; they had him on video.

Yeah, I always tell patients the exam starts when they get in the car and ends when they get back in the car. You know, because I’ve had examiners look through windows and stuff like that. So yeah, it’s important. You know, I also talk about this idea of a walker. Like, I ask patients if they use a walker. They say no. I ask if they go to Walmart, do they lean on the shopping cart? They say, I can’t go anywhere without the shopping cart. So that shopping cart is really a wheeled walker. So I make sure the patients can describe things in a way that the examiner can understand.

Yeah, that’s true. My wife does that sometimes. When she goes into the store, she grabs onto a cart and uses it. Yeah, it does help. Patients don’t really think about that as a walker, so that’s important. That’s one of the big questions though. Most of the orthopedic DBQs talk about if you use a walker, cane, crutches, wheelchair. What is your opinion on the DBQs now? Do you like the format or do you think it could be improved?

Well, like I always talk about the fact that they could always be improved, but you know, I’ve got them memorized now so I don’t worry about the format so much anymore. I can just go through them. But you know, there are 65,000 codes, and there are only 70 DBQs or so, so they’re kind of a broad brush. There’s a lot of stuff in each DBQ that doesn’t apply to the specific rating. Like, I’ll leave things blank, and patients go, hey man, some of these things are blank. So a lot of stuff doesn’t even apply because it’s just a shotgun approach. You know, like I say for the knee, a lot of that rating is based on the range of motion and stability. There are eight pages of questions that don’t really match up with the rating schedule. It’s confusing. A lot of VA doctors, there are places on the spine DBQ where it asks always questions about spine disease. Towards the end, it asks a question about whether the patient has intervertebral disc disease, and a lot of the VA doctors will check that as no when the patient has it. So the DBQs are confusing to the medical logic because our logic, the way we were taught to do exams and evaluations, is in a different order and a different logic pathway. So the DBQs can be confusing to the physician until you memorize them because they’re kind of backwards in a way. They’re more of a legal document than a medical document, so it’s kind of hard to mesh it sometimes.

Well, wouldn’t a DBQ be better, doctor, if it had a place for you to write an opinion?

Yeah, yep, you’re exactly right. On the DBQ, usually question two, three, or four somewhere there asks a question about what the history is, and they give you like a quarter of an inch. Usually what I do there is I tell the patient, see attached lay letter, and let them write as much as they want. I have some lay letter samples that talk about where it happened, what happened in service, what happened now. There’s no space for it. And the same thing for the doctor. Towards the end of the DBQ, many of those DBQs only have like half an inch or an inch space to try and write something. If I do my Nexus letter, my Nexus letter might be one, two, three, or four pages for each issue, depending on how big it is. I might have integrated lay letters, I might have integrated some literature, I might have brought in some new imaging tests, and I put in rationale. I might critique the doctor’s opinion. There’s no way I could put that in half an inch on the page, even if I typed it really small. So it’s almost a setup for failure because it doesn’t give the doctor a chance to explain himself. So then if you fill the DBQ out and send it in, the VA might say no rationale and deny it because there is no rationale.

Yeah, but when the CMP examiner writes an opinion, because usually they say, you know, it’d be a figment of my imagination or something.

Yeah, speculation. Yeah, you’re right about that because the VA has their own special website for DBQs. You might have seen some of those. Some of these DBQ forms look different than the ones the VA doctors use. The ones the VA doctors use look a lot different than the ones they issue on their website.

Yeah, I had one for heart disease here back in the last or later part of last year. They sent me a DBQ. I filed for a fib arrhythmia, and they sent me a DBQ for hypertension. So I had to get the right one printed off, take it, and get it filled out. Then they went back to the CMP examiner, sent an addendum to her, and asked her the same questions over and over again with an opinion. That’s the first time I saw their own internal form. It was on E-Benefits. I got what’s this? Then I saw what it was. It had a place for internal VA use only, and then it has a section that says rationale and opinion. It has a big place prompting the doctor to provide rationale, whereas the other DBQ just says comments or something like that. So, you know, it’s weighted in favor of the VA.

The other thing you just mentioned was the fact that a lot of the doctors do their DBQs online. They have an online form, so they could type a couple books in there. There’s no limitation on the space they use because it’s just online, whereas the paper ones are limited to the space you have. So unless you attach something to it, it might get lost. So yeah, it’s weighted. The whole thing’s weighted in favor of the VA because it’s not issued to the outside doctor doing DBQs. They’ve got so many DBQs. It’s a crapshoot. The veterans have a method to do it, and veterans just have to get a medical opinion to find out what’s wrong with them.

Yeah, that’s right. A lot of these veterans have complicated diseases. That’s part of the problem also with the PAs and nurse practitioners. They don’t have much experience or are younger and often aren’t as old as the disease process in the patient. For example, they’ve never seen anything that extends that long over time, so we don’t have a good chance to describe what the history is.

Yeah, that’s why we have good doctors like yourself and a few other folks who actually can navigate this system. A lot of folks try to navigate, but they can’t do it. But, you know, if you’ve been doing this as long as you have, how many years have you been doing this now?

More than 20, for sure. My first one was probably in ’86, maybe 30 years now. Time flies.

30 years, it does, doesn’t it? So, yeah, that’s crazy. The other thing is that a lot of these cases extend back over 30 years, and the rules that applied 30 years ago might still apply under CUE. Some of the rules that applied five years ago may still apply to cases that are pending. So it’s nice to have that perspective on seeing the VA change over time because I know kind of how it’s supposed to go, and my thinking might be in line with the DRO because the older guys have seen the same series of changes.

That makes a lot of sense. For example, if you file a claim and it’s so many years old, your condition has to meet what the regulations stated at the time, not in today’s current world, but it happened back in 1986 or ’85. That’s what they look at. They have to use the regulations back in effect at that time, the covering time period. They change a lot. They try to reduce a lot of stuff, and they try to take severities away. It’s just a headache.

Yeah, so we talked a lot about, I think one prior show talked about strain. The VA has gotten on this strain a lot, where instead of giving people arthritis, they called it a strain, which maxes out at like 10% instead of higher percentages for arthritis. They’re kind of using the schedule against the patient. Patients don’t realize if they’re rated for lumbar spine strain, it’s a limited rating because it’s not full-fledged arthritis. Strain is not really, I mean, it’s just a strain. Unless you’ve got an MRI showing you’ve got some disc problem and bone problem, that’s not a strain, that’s arthritis. You get a whole different rating.

That’s right. But they also have, with back injuries, two sets of criteria. They’ve got intervertebral disc syndrome and they’ve got traumatic arthritis. It’s rated under two different programs.

Right, right, right. You’ve got to be able to separate those two out. That makes it difficult. Would scoliosis fit into that program of arthritis or traumatic arthritis?

Yeah, scoliosis is just a description of a little bit of a curve, you know, like an S curve for scoliosis. It’s kind of like the way I think about it. But a lot of people have a little bit of a leg length difference. Nobody has perfect leg length, and a little bit of leg length will cause a little bit of a spine twist. Over time, I had a guy this week that came in and had scoliosis. On the way in, I said that his was aggravated in service. He came in fit for duty, and then his back was aggravated in service. It went to the VA, and the VA judge said I was inconsistent. The sidekick judge said I wasn’t inconsistent. Scoliosis is a sort of normal phenomenon, but when he was in service, his back degenerated. It was aggravated over time. So that’s totally consistent. You can come in fit for duty with scoliosis; almost everybody has some scoliosis. The judge didn’t really understand the medicine, and that’s why it was confusing. So then scoliosis can cause, you know, pathological scoliosis can be caused by a lot of things, like you mentioned, arthritis, or maybe a vertebral body fracture, or maybe somebody had an amputation or leg length shortening or something like that. So there are a lot of ways for it to occur.

Something of interest you guys might want to know about, which is very interesting that I saw last week, is that they’re using large pieces of parachute cord with some screw bolts into the spinal vertebral bodies and using the parachute cord on the convex side of the curve to straighten the curve out under the elastic tension of the nylon cord or whatever, something like that. That’s a pretty interesting thing because usually they always put rods in, big rods trying to straighten out scoliosis. This is a little less invasive kind of a new thing.

Yeah, the rods are stiff, whereas this parachute cord-like stuff is flexible.

Yeah, that’s a new little twist.

We’ll call that the BU procedure, right?

Yeah, Bue procedure. Big old cord.

Let me ask you about scoliosis. A lot of veterans have scoliosis because a lot of veterans have other issues. For example, a spinal cord injury, we’ll touch on this later, but people with paralyzed diaphragms, like one side, say it’s the left side, your shoulder on your left side when your diaphragm is paralyzed always elevates. You can see it on X-ray, that’s how they usually catch it. Over a long period of time, where that shoulder stays elevated, that’s going to cause you to have scoliosis.

Yeah, anything that throws the body out of balance can cause scoliosis. Whatever is causing that muscle paralysis in the diaphragm is probably causing some paraspinal muscle problems or other types of strap muscle problems. It might be coming from your neck, for example. Then that’s going to cause the shoulder to modulate, maybe in a compensatory fashion or whatever. Then that’s going to change the weight balance on your spine and aggravate everything. You might not use your shoulder right, and that shoulder might go bad because it’s being overused. The wrist might go bad on that side because of the same kind of thing.

What about atrophy in your shoulder if you have a situation that means you waste away? I’ve seen some folks whose shoulders are elevated like that, but it’s half the size of the other shoulder. They’ll be wearing a shirt, and the sleeve will come down on the right side to near the elbow, and on the left side, it goes way down past the elbow.

Yeah, right. Atrophy, if you don’t use something, it atrophies. But also, if you have nerve damage or muscle damage, you can atrophy on that basis too. The VA has a lot of questions in their DBQs about atrophy. It’s a sign you can see, and you’ve got to try to figure out the cause of it. In cases like that, a lot of times age causes the atrophy because the muscle’s not being used, or like the light switch, it’s turned off, not getting any juice.

Yeah, that’s true. It has a lot of effects on people. It’s been rough on me. It affects my entire left side.

That’s a huge problem. Also, you might get contractures from it. Say, for example, you lose your triceps, which straightens your elbow out. Then your elbow is perpetually bent, and when you have a perpetually bent joint, it can fuse, or the biceps can get tight, and you have contractures. You see a lot of stroke patients or paralyzed patients who often have contractures because they can’t stretch for range of motion.

Makes sense. Again, I don’t think the DBQ has enough about that situation. I’ve never actually seen one for certain spinal cord injuries and things like that, but I’ve seen just different muscle skeletal issues with your back and bones and discs, but it doesn’t really cover much on the neurological side.

You’re probably right. The DBQ doesn’t really cover it. Well, spinal cord injuries, you want to get into that, but spinal cord has multifunction problems. The DBQ, like I say, is mostly muscular skeletal, range of motion, and so on. But the spinal cord has 10 million fibers going down there, so there are a lot of functions that are going on. For example, most of those DBQs don’t talk much about the neurogenic bowel and bladder part, which is huge. The bladder can be like 60% by itself, and the bowel can be 100%. Those are huge problems with the spinal cord that could kill patients, cause infection and sepsis, and you get skin breakdowns because you can’t feel. The DBQ doesn’t talk any about the skin breakdowns, decubitus ulcers. The DBQs don’t really talk about contractures from spinal cord injuries, as I just mentioned. You could have knee, hip, or ankle contractures. You could have heterotopic ossification, new bone formation from little traumas or fractures that you get in your hip joints. The DBQs don’t talk about any of that kind of stuff. They don’t really talk about erectile dysfunction either, which is something that happens with the spinal cord a lot that patients have problems with. Then, if you have catheterization for your bladder, you might get urethral strictures, or you might get urethral blind pouches. Same thing with the rectum, if you have to do digital stimulation, you might get fissures or some kind of little neuromas, or you might get a prolapsed rectum if you have complications and have surgery with a loop or something like that. If you have a colostomy or some kind of ostomy to drain your superpubic catheter, none of those DBQs really talk about any of that stuff. You’ve got to really know the medicine. A patient like that comes in, and I really dig into it because a spinal cord patient, stroke patient, or multiple sclerosis patient all kind of have a similar final common pathway. They’re going to have bowel, bladder, skin, erectile dysfunction, contractures, and muscle issues, blood clots, blood clots to the lungs, things like that.

You touched on strokes and things like that. You know, of course, if you have a stroke, there’s a window there that they have to give you TPA to try to reverse the effect of the stroke.

Yeah, there’s a lot of ins and outs to that. So stroke, there are a couple of types. One’s a bleeding stroke, and one’s a non-bleeding stroke. That TPA stuff, I was around when they first started using it at GW 20-30 years ago. There are a lot of protocols out there about how much time you have before you can give the TPA or how long you wait. One thing you don’t want to do is give that anticlotting stuff to somebody who’s having a bleeding stroke. That’s one of the big things because you can make the bleeding worse. Usually, they want to do a CT scan to make sure there’s not a lot of blood there, and then there’s a window of time. I went to a conference last winter, and they’re talking about increasing the window, maybe even up to 18 hours or even a day later, a lot longer than what we used to think. I used to think like an hour range, but now it might be in the day range. That’s the whole justification for the rapid transit systems like the Maryland Shock Trauma system that’s all over the country, trying to get people in quickly. So that’s one thing you can do is put the TPA or something like that directly in the vein. That helps. Or you can put that stuff inside a catheter and squirt it right into the clot if you know where the clot is, if you find the clot on the MRI scan or angiogram. Besides that, you can also put in these little corkscrew things that go into your catheter. You can actually corkscrew in and pull the clot out that way if you find a big one. Or you can go in with a snare, like a little snare you might use to catch a rabbit with. It’s a little wire loop. You can take that and sometimes you can wrap that around the clot and pull it out. It’s all about trying to get blood to reperfuse the brain. My analogy is if the sprinkler head goes out in the grass, you’re going to have a dead circle of grass. Same thing in the brain. If you fix that sprinkler head so the water, or blood in this case, can perfuse the brain, you’re going to have a lot fewer problems with the stroke. So, it’s evolving. The type of method is evolving: how you give it, how long you give it, how fast you give it.

Thank you all for listening. That ends this show. Now I’m going to zoom off.