Introduction

“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.

Guest Speaker Introduction

Our guest speaker today is Dr. Craig Bash. He’s a Veterans Medical Advisor. So, if you have any questions or comments, feel free to call in. Our number is 347-237-4819. Now that number once again is 347-237-4819. When you hear some lady talking, just hit one while she’s talking or after she talks, and that’ll bring you in the queue with us. So feel free to call in. How are you doing today, Dr. Bash?

Discussion on New VA Processes

I’m doing good. I’m kind of worried about this new VA process and the way they’re going to try and process claims. You know, it’s a concern.

Yeah, we’ve been talking about that for a good while. Being new, it’s always a concern to me. It takes them so long to get the bugs worked out of things, and is it even feasible? You know, who knows? Are they going to make the process better, or are they going to make it worse?

The big thing I worry about is trying to put in new evidence. One of those pathways talks about how you can go for a higher level review, but you don’t get to put new evidence in. New evidence could be my medical opinion or new medical data. Not having new evidence could really hurt the claim because oftentimes the veteran doesn’t know what he needs, and medical testing gets better over time. They have a better chance of success with more evidence, I think.

Challenges in Submitting Evidence

What I run into, Dr. Bash, all through my claim, is they were sitting on the evidence that I needed. By the time I’d get my hands on it, it would be several years down the road, and then I’d have to submit it. It coming from the VA is problematic when they mention that you can’t put in new evidence. Many times it’s years before you even know it’s there. Of course, they can never find it. You have to give them the page number and everything else. You got to nail it down for them and put it in their hand before they’ll consider it. Now, with medical evidence such as what you provide, that’s a little different. But the evidence in your records, they won’t go hunt for it. Even if you tell them it’s there, they’ll just say they can’t find it or it doesn’t exist. When you realize it really does, it could be five, six, seven years down the road.

Yeah, some of the VA people told me that they won’t let them do new testing. Like, in the old days, if they had a question about some issue, like if they needed a chest x-ray or an expert opinion, they’d go out and get it. But they’ve told them now if the evidence isn’t there, just deny the case. If they won’t allow new evidence, it makes it very difficult for the veteran to be successful, like you’re talking about.

Philosophy on Handling Claims

Oh, they won’t be successful unless they get a VA doctor to work with them, which is not very likely.

So, my philosophy now is I’m trying to do a lot of these cases with the evidence up front. In the old days, I might write an opinion saying that this was this way because of this reason and that we might need a certain test. What we do now is try to get the testing done ahead of time. I might get a podiatrist to weigh in, I might get a neurologist to weigh in behind me, I might get a pulmonary doctor. So by the time the claim is ready to put in, I have my opinion plus I might have three or four other doctor opinions behind me with all the needed evidence.

The way it’s structured now, I can see that that’s about the only way you have to go, isn’t it?

Yeah, try and get it in up front. Which is hard because the veteran, you know, it’s costly and time-consuming. But the other thing is that they might have that thing called a supplemental appeal. One of those pathways has a supplemental appeal. I think the supplemental appeal, my thought was that in the supplemental appeal, I might do another medical opinion with a new medical test. Like I might order a new chest x-ray or we might have a new pulmonary function test, something like that. It would be relevant because the VA is going to say if it’s not relevant, they’re not going to admit it. Another way to do it would be to get a second physician behind myself to have their opinion. So Dr. Bash says this, and Dr. Jones says that. That’s another piece of new relevant information which would allow new information to get into the file. I guess you can do that three or four times, and then after that’s over, if you’re still at the stress, then you got to maybe wait until the BVA, which could be years like you’re talking about, six, seven years.

VA Cooperation and Challenges

That’s unfortunate too. If the VA would really honestly work with a veteran, they got his doggone file. They know what’s going on. They shouldn’t have to depend on the veteran to tell them. Dig it out themselves somehow.

These RA guys told me they’re trying to do things so fast that if the Raider asks for information and tries to get tests, it slows them down. So they’re trying to put the workload on the patient, which is not right.

Yeah, and that’s what they’re doing. Many times a patient doesn’t remember years back or something could have happened. It might be in the records.

I have found getting a proper claim file out of the VA is really difficult. I went through five different claim files they put on CDs for me, and each one gets larger. How does that work? This additional information could have been utilized from the get-go. There’s something seriously wrong with that. You should have a real-time claims folder that you can look at. I know they have for some of the VSOs and stuff, or claims practitioners, they can get that access, and lawyers, but a veteran can’t get it.

Access to Claims Files

Yeah, because once the veteran gets it, they can get it to some expert like myself. Secretary McDonald was very good at that. We used to write a letter to him, and he could get the claims file in a couple of days and fix it out on a disc. The VA can do that if they want to, but they don’t really seem to be that invested in that process. A lot of the data inside the records is not being looked at. You’re right.

That’s one of the things I was going to touch on a little bit. CUE. Bill Kriger wants to come on in a month or so and talk about CUE in a deep way. Some of the examples that I find on the medical side is that they don’t look at or understand the terms. Like, some have a little fracture in their spine called the pars defect, and the Raiders will go by it, not realizing it’s a spine fracture. Or things like reactive airway disease, they’ll miss that it’s in the record. It’s a precursor for asthma. Or they’ll miss some of the stuff with the nerve distribution in the hands for spinal cord, confusing the C6 and C7 roots. Bill’s got a good case on that. Not only is the record not presented as well, the Raiders aren’t looking at it as carefully as they could to find these details that can make a big difference in the case.

They’re trying to get Raiders to do cases in 30 minutes now, really pushing them fast to get things out the door. A lot more sloppy evidence.

Concerns about RAMP

Well, they sure didn’t do mine in 30 minutes. But anyway, it’s a new process, Dr. Bash, and it’s got to be proven up. If they can’t prove it up pretty soon, we’ll find out because when everything is piled in this… what’s this new process? I keep wanting to call it fracking, but…

RAMP.

RAMP, yeah. When they claimed they made such headway on the claims process, it all went to the appeals. I think that’s what you’re going to see here with the fracking program, or I mean RAMP program, is everything’s going to pile up in the RAMP program, and they’re not going to be able to meet the timelines that they have indicated. That’ll tell the tale.

Yeah, and I understand they’re already getting behind rather quickly.

I saw a case last week that came through. They’re already starting to talk about the relevant evidence. They said the information presented wasn’t relevant, so they’re going to discharge it. Like if the veteran puts in redundant evidence or literature and things like that, they’re just going to say it’s not relevant and push it back. So that relevant evidence is going to be an interesting definition.

Impact on Veterans

That could be detrimental to a veteran for sure because I can certainly understand there could be relevant evidence out there, articles, newspaper articles, or memos. You run across all sorts of different things. I mean, the list could go on. Just because the Raider doesn’t think it’s relevant doesn’t mean that it isn’t.

The Raiders are being pushed a lot on that M21 too. And Creger was talking about that a little bit. He said that the M21 often doesn’t relate itself very much to what the laws are, so the VA kind of makes up their own internal rules and puts them in the M21, and the Raiders follow. But they’re not really necessarily backed up by the legislature. I had an argument with them. I’d say, “Look, if you just read this thing, here’s what it says.” And they’d say, “No, no, that ain’t my interpretation.” It’d be something so obvious that it’s crazy.

The RAMP program, I think, will show its ugly face here in six months, less than a year. It’s going to be…

Like I said, there’ll be 500,000 behind there waiting, and they’re just changing names of the same problem, just giving it a new name.

Vascular and Cardiac Issues

Yep. So, JB asked or wanted to talk about something about vascular things, right?

Yeah, speaking of cardiac heart disease and a little bit of PAD, things like that, peripheral artery disease.

Yeah, so the ideology is something that’s toxic in the blood vessels. So we talk about Agent Orange or diabetes with high sugar levels. Those toxic things can cause the vessels to react in an inflammatory way. So that’s why you might have ischemic heart disease where the vessels get narrowed, and you might have basically ischemic changes in the legs for artery disease, arteritis obliterans. It’s kind of the same common pathway. I’m sure I haven’t looked at it closely, but we know diabetes causes changes in the brain, and you get things like dementia and mini strokes due to those same kind of vascular changes in the brain. The end organ responds the same way. When you don’t have enough blood to whatever organ it is, it starts to lose function. Like in the heart, you might get angina, chest pain. In the legs, you might get claudication where you walk a certain distance. The VA tries to…

Treatment for Vascular Issues

Is there any treatment for that? If you have what they call hardening of the arteries, especially in your legs, is there any special medication a person can take?

It all kind of depends exactly what the cause is. There are lots of ways to get sort of overlapping problems. So if you have high blood pressure, that can cause some arterial narrowing, you know, the hardening of the arteries classically. If you have high sugar, that can cause problems. If you have toxic exposure, that can cause problems too. So you might have all three of them: sugar, Agent Orange, and blood pressure. If you can treat part of them, get the blood pressure down, maybe fix your cholesterol, get that corrected, then some of that stuff can be reversed a little bit. The toxin, like Agent Orange, is probably a little bit more concrete, not as reversible. But the body is always trying to make things better. If you can optimize the environment, there’s no real magic bullet. If you have a real single narrowing, that’s where you get those stents and they do vascular surgery and put new vessels in to try and correct that stuff. But a lot of this can be chronic.

Seriousness of Vascular Issues

What about if it gets so bad your feet go numb? I know several veterans that claim their feet went numb. That’s a serious situation, isn’t it?

Yeah, it’s a huge problem. The vessels, there are little small blood vessels, vasa vasorum, that run along the side of the nerves. So when the blood vessels start to get damaged, those little vessels that supply the nerves get damaged, maybe even early, and then you get those problems with the nervous system. You get that peripheral neuropathy from different causes. You get numb feet, loss of balance, and you may need a cane, you may fall, and you get yourself the high levels of SMC based on loss of use and loss of balance, not even amputation or spinal cord. It can be based on peripheral neuropathy. Yeah, it’s a very serious… You can cut your foot, burn it, and get infected. People can die from all those secondary complications.

Preventative Measures

It’s not really possible to go in there and do what they call a “roto-rooter,” go up there and clean the plaque and stuff out because if you chip that plaque up and it starts breaking loose, it could cause a stroke or worse.

Yeah, stroke in the legs. You might lose your foot. The flow depends on the process. Some processes are continuous, like a freeway jam all the way down the freeway, and other processes are more like a bottleneck at an intersection. If you fix the red light, you can fix some of those different things. That’s why we do imaging and angiograms to try to find out exactly what’s going on there to tailor the treatment.

The VA rates those things based on function. In the legs, they talk about claudication, the pain you get over a certain distance. They measure like 100 yards and give you a certain number. They also measure it based on this ankle-brachial index. They take the blood pressure in your wrist and compare it to your leg. They should be pretty close even though they’re a little bit different distances. If that index is less than 0.9, they can give you a higher percent, like 20%. Same thing in the heart. If you have ischemic heart disease, they rate you based on METs, metabolic units. They measure that by how far you can walk or climb stairs, and they’ll give you different levels. There’s a chart you look at. Or they can put you on a treadmill and measure your oxygen to get an idea of what’s going on that way. Anybody who has chest pain or leg pain when they exercise or work out should be an indication that they might have these ischemic places where the blood’s not getting into that organ, you know, the leg or the heart.

Cholesterol and Heart Health

Got a question, Dr. B. Now, what if you had those symptoms, symptomology, you know, you have that, but say your cholesterol is checked regularly and your cholesterol is in good shape. You take anti-stat medication or whatever. What would be the factor in that issue?

You try to separate cholesterol problems versus the problems you might get from Agent Orange or diabetes, right? You’re talking about trying to split out those processes. It’s like a process of elimination. If your cholesterol is good and it’s been good, that might be a less likely problem. Then you can check the blood sugars and see what that’s like and check the toxin history, check the blood pressure. You can also do some manual testing where you measure the pulses in the leg and see if they’re normal. If you’re confused about it, you can get that test, that ankle-brachial index test, and see how that works out. If that’s low, then you have sometimes a situation where you have two processes that can give a similar result. In cases like that, I always know, the tie goes to the veteran. I would say something like, the patient had some high cholesterol but now it’s under control. We know that cholesterol could contribute to this process, but we also know that he’s exposed to TCE or Agent Orange or has diabetes, and that could also do it. In my opinion, it’s impossible to tell which one was the causation, and the veteran should get credit for one of them.

Uncontrolled Hypertension

How would 35 years of uncontrolled hypertension factor into the mix?

Yeah, same thing. High blood pressure causes the same kind of deal. It causes those arteriosclerotic changes. The blood pressure damages the intima of the wall, and then the intima gets a little bit damaged, and then the plaque can stick to it if you have high cholesterol.

Also depends on…

Yeah, exactly. It kind of depends on turbulent flow, like places where you have intersections. There’s a lot of turbulent flow, and that can cause the plaque to build up, like the bifurcation in the femur is a classic place where you have turbulent flow. That turbulent flow also is what causes aneurysms to form oftentimes in those junctions because it makes it a little bit weak there. Chronic hypertension can be a contributor to it.

The size of the particles makes a difference too. They’re starting to do MRI scans, so microscopic type of MRI measures the size of the particles. It turns out that not all the cholesterol particles are made the same. Some are kind of fat and juicy, and some are kind of small and thin, like little ones. They talk about the LDLs as smaller type particles, but there’s even some breakdowns in those. The small little particles can get through the wall of the vessel. If you have that turbulent area, have some damage to the wall, the little small particles can get inside there and start to build up the plaque in the subintimal area. The big fat little juicy ones, like dump trucks, they just kind of roll by, and they can’t get in and cause damage. It’s not just the raw number of particles, it also has to do with the size of them. That’s why if you take different types of medications or even vitamins, you can change the particle size. When you do that, you can actually start to change the vessel. You can get some reversal or some of that stuff.

Conclusion

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