Thank you for taking time from your busy day to watch the special presentation from the El Paso County Medical Society.

I'm Dr. Joel Hendricks, president of the El Paso County Medical Society.

And it is my hope that you will find our program of great interest, educational and informative about the medical care provided by some of our best physicians in our country right here in the Borderland.

From all of us at the El Paso County Medical Society, please enjoy tonight's program.

It's a condition that affects 12 million Americans.

Dull cramping, pain in the legs, hips, thighs, calves and the bum.

Numbness or tingling anywhere in the leg, the foot or the toes.

Changes in skin temperature or in color.

Infections or sores that do not heal.

These could all be warning signs of peripheral artery disease, otherwise known as PAD.

The arteries of a peripheral vascular system carry blood to the arms, the legs and the feet.

But over time, and with certain risk factors, clogged arteries can result from a buildup of fatty deposits or plaque.

Most commonly found in the legs and the feet, complications result in over 160,000 amputations every year.

But if found early, if early detected, it is relatively easy to treat.

And that's what we're here to talk about this evening.

We want to thank Tenet, The Hospitals of Providence, for underwriting this program this evening.

We also want to thank the El Paso County Medical Society for bringing the show to you for over 26 years.

I'm Kathrin Berg, and you're tuned into The El Paso Physician.

Thanks again for joining us.

We are talking this evening about what you need to know about peripheral artery disease.

And we have with us a veteran this night.

We have Dr. Laiq Raja, M.D., who is an interventional cardiologist.

He also is a endovascular specialist and a medical director of the Department of Cardiology and critical limb ischemia.

We're going to learn all about that tonight at the memorial campus of The Hospitals of Providence.

And with us also, we have Julie Berumen, who's a nurse and a patient navigator at the hospitals of Providence.

And she, as Dr. Raja describes, is the quarterback for the SEAL Eye Program at Memorial.

So thank you so much for being here.

And my favorite part of doing these programs is always the 20 minutes that we have before we actually start taping.

And there was a certain point, Julie, that you were talking.

I'm like, wait, we have to say that because this is like information gold.

So on that note, since you are since you're the newbie, I'm going to have Dr. Dr. Raja go for it.

Dr. Raja Yes.

I described what your title is, but when we talk about and you've got a lot of titles, when we talk about specifically this program and relating to what we're talking about this evening, describe to our audience what it is that you do all day, every day, so that there is an idea of what the questions are going to be asked of you and Julie.

You're going to be next.

So and I know you said it's going to take you a half an hour, but that's okay, because that way we really know the description.

But Dr. Raja Well, as my title says that I am a interventional cardiologist by training and then also endovascular specialist.

What does that really mean?

Is that with time and with the need, the interventional cardiology has grown to an extend to be not only taking care of the heart and we are taking care of the entire body.

So as a endovascular specialist, I do take care of patients with peripheral artery disease.

So my day is usually is a mix of both.

Somedays I'm doing more cardiology and some day I'm doing more vascular work right.

And then obviously related to all the different procedures and hospital follow ups and drones and all in vascular is all about the heart anyway.

And so, Julie, when you first started talking about what's happening, you had a great point is people always talk about the heart.

People talk about cardiology.

But this is so related to the plumbing system of the heart for you to describe.

And I know we joked about it, but for you to describe of what you do.

So Dr. Raja called you the quarterback.

So you're the person that you got to throw it out, right?

So what is it that to describe to our audience that you do all day, every day?

So I think what's really unique and I love the job because I get to do everything and nursing, so I get to fight.

I'm the person that finds out a patient is coming into our hospital, whether they're in the emergency room or they're being directly admitted.

Where this situation or an intervention or diagnosis, they have wounds, they're coming in, they call me, and then my job is to be there for the patient and family.

I am there to guide and direct them through this process, inpatient and then also work outpatient with other navigators and other case managers and facilities and doctors once they go home as well.

Okay, So basically I educate the staff, I educate the patients.

I work with all the physicians that are caring for that patient, and I help them stay updated as to what is going on so everybody can collaborate together.

There's no overlap.

There's no, you know, to, you know, procedure, duplication or anything like that.

It's sort of like help the flow for the patient and also alleviate, I think, the stress because it's very stressful being a patient in a hospital and being, you know, not knowing what's going on.

You know, we're comfortable walking in those hallways, but not only as a patient, you know, you're scared, you don't know.

A lot of the terminology may not be familiar with you.

This may be the first time or you may feel bad because you're coming in a second time and it's not a failure.

It's just part of the process of the disease.

And they want to know everything that's going on.

And I think just knowing somebody cares and they deal with one person right?

That helps sort of decipher all the other professionals for them.

Don't let me forget because you hit on such a great point I want to go through defining what this is, what is and what also is.

But I would like in the back of your head to think, okay, what is it that people are coming and presenting to you with?

Like is it an emergency room?

Like I'm having a problem walking and we have to talk about that now.

What I want to do now is, is talk about what the definition of peripheral arterial artery disease is.

And that also we talked about the vascular system.

Right.

Maybe we can talk about that in conjunction with peripheral vascular disease.

Are they the same thing?

Are they a little bit different?

Because I know you, I see them often interchangeably.

So, Dr. Raja if you can address that, and then I'd like to talk about some of the signs and symptoms where people think, oh, something's really wrong and I need to go check this out.

So if you can do the definition for us.

So make it simple.

When we say peripheral is like on sites, right?

Yes.

So with the heart is the focus and everything getting out of the heart is peripheral.

Right.

Okay.

So peripheral arterial disease is not the heart, but other parts.

So the process just happens in the heart.

The artery gets clogged and you can have a heart attack.

You're going to angina or the heart disease.

Now imagine the same process happening to the carotid, which takes the blood to the brain so you can have a stroke, Right.

The process going to the limbs.

If those arteries taking the blood down to the limbs, they get blocked.

You have no circulation.

Then started having symptoms.

That is mostly that's the peripheral artery disease when we talk about in the lower extremities.

But it can happen to any part of the body.

Right.

And the arteries of the body.

So in the peripheral arterial disease, which is arteries.

So I usually explain my patients arteries and the veins, it's like it's like a interstate.

If one is going that way and one is going that way.

Right.

And then talk about the blue and the red right.

So they are next to each other, right?

But they never connect except there is an access you have.

You have to take an exit right that way.

So when the heart pumps the oxygenated clean blood, it goes through the arteries to all over your body.

Once the oxygen is extracted and now the blood has to go back into the heart, into the lungs.

It goes back through the veins so you can see the veins in your skin, under the skin that kind of little bluish color.

Right.

Because they are have less oxygen.

They are an oxygenated blood.

So this is the one which is going back.

So peripheral arterial disease is mostly the arteries.

Right.

But when you say peripheral vascular disease is all of us, the whole system.

So it could be veins, could be arteries.

And many of us, we talk interchangeably.

Okay.

So if you if you're looking at it as someone who's a layman in this area, it is interchangeable.

And so the reason I say that is or not, I'm going to I'm going to call it peripheral artery disease all day long just for me.

But I know that people see PVD and PAD, and I just thought I'd explain that.

On that note, Julie, let's talk now about someone who let's talk about signs and symptoms.

First.

Let's talk about signs and symptoms because when people think about having a heart issue, a cardio issue, they don't think about arms and legs.

They don't think about why are my legs getting tired?

You know, they think maybe it's something else.

So when you have patients asking you questions or coming to you, how does that usually present?

What are the symptoms that they're coming to you with?

They can have anywhere from.

It's similar to the heart where they have pain.

When they're exercising, it's relieved with rest and then as it progresses, it doesn't get relieved anymore.

They have it in their sleep, wake them up at night.

Some people even describe the symptoms as an electrical shock, going down their legs.

Mm hmm.

And it comes and goes cramping.

There's patients or people out there that you know what we have known as peripheral neuropathy because they're diabetics and they may not feel it, which is true of the heart as well.

And so a wound will occur.

They'll hurt their toe or something and it won't heal.

And that'll be a sign that there's something going on down.

So I'm going to quickly, because we do a lot of diabetic training on this show.

When you say a wound that won't heal, I automatically my brain goes to diabetes.

And so that is also a big risk factor.

Another area that specifically in El Paso with Hispanics is a very high prevalence area of diabetes.

Talk a little bit about that.

We'll go more into depth in that as a show progresses.

But usually sore that doesn't hear heal people think diabetes how is that associated with diabetic are definitely associated with PAD One, they're when their blood sugars are not controlled and they're not or don't know that they have diabetes, There's people out there that are thirties, forties.

They have a history in their family but they've never been tested and so it's uncontrolled.

They it affects as the sugar stay higher in the system it it it contributes to the the closing of the arteries more and they also as well as the healing does not occur as rapidly.

It's basically because of bad blood flow, blood flow and blood sugars and blood sugars.

So we talked all sort of work together.

Okay.

Which makes perfect sense.

And you were talking earlier and Dr. Raja, I'd like to ask you about this.

So there is a blood test.

And to your point, we're talking about annual exams where you get your blood tested once a year.

But there's a blood test.

The agency that you all were talking about that is a like a blood sugar monitor that kind of goes back for three months.

So you all were telling me about this and I wasn't completely informed about this.

So talk about the blood test agency.

How often should someone with diabetes get this test and maybe explain what it is?

So the hemoglobin A1 C, as Julie was explaining a little while ago, is that usually you can check your blood sugar now and it might be okay, but 2 hours later it's high.

And to your point, usually when people have their blood tests, it's after a night of fasting.

Yeah, they're looking at everything else.

Your blood sugar is going to look beautiful after fasting, so that's why I wanted to hit on.

Yeah.

And then in the morning, you check your blood sugar too, which is very if it's just, you know, close to normal to you, you know, that your blood sugar is very control your diabetes.

But then you go out and you know, you had a big meal and after that you have something else and you sugar runs 300 something.

So how do we know as an average So hemoglobin even C is a test is a blood test, simple test, which tells you how well-controlled your hemoglobin agency is.

For example, there are two people you check their blood sugar, same time.

One, both of them.

One has 105 and one has 110 always the same.

Hmm.

But then if you check the hemoglobin A1, C one is seven and one is ten.

Hmm.

Mm hmm.

That tells you the person who has a ten hemoglobin.

See, that has a very poorly controlled diabetes, no matter at this moment is hundred and ten.

So here's my I don't know if this is the question.

I'm in my head thinking, okay, how does this test detect 2 to 3 months of data with a blood test?

Like how how, how it's interesting to me how long that stays in your system to be able to detect that with this type of a blood test.

Physiologically, how does that work?

And if that's not something we can go into.

Right.

Is it just it baffles me that, you know, a couple of days later, okay, well, everything you did a month ago doesn't count.

But we're looking at three months back.

That's why every time you go to your primary care physician, I don't think anybody asks you anymore, how's your blood sugar now?

What's your hemoglobin A1C?

The recommendations by American Heart Association or diabetes?

Everybody focuses on A1C.

Interesting.

Okay, so it's not just a simple blood test.

Julie, let's talk about risk factors.

I don't know, is there genetics?

Is that play a part of this at all?

I know the lifestyle.

We can talk about lifestyle and again, feel free to bounce back between each other when these questions are thrown out there.

So hereditary factors are obviously things you cannot change, but there's many things you can control by medication such as diabetes, high blood pressure, hyperlipidemia or high cholesterol in the blood, which is the same for the heart high blood sugars, smoking.

Hmm.

Can't change race, can't change, you know, geographical age if you're over 40.

I know.

Sorry that we all that might be that might be in the future.

But for right now.

But so, you know, those kind of things aren't changeable but there there's with early detection again and being aware and knowing, you know, that this is something that is just as important as checking your heart and, you know, all the other things that, you know, or cholesterol stuff that's controllable.

So those are things actually smoking is a big factor, too.

It affects just like the heart.

I always say this is like heart of legs.

It causes heart attack.

That's a heart attack of the legs and arms.

It's it's just outside of the heart, but it's the same.

So explain to people who are smoking.

My my mother died of lung cancer.

So everybody knows I'm like this smoking.

Yeah.

So constriction, right?

If you're looking at smoking, what is it that's happening in your body when you smoke?

And I just think about you think about your little blood vessels and they just get a lot smaller because it's it's doing that stimulus there and it's small.

It's toxic to your body.

It causes this constant inflammation in your vessels walls and they react to it by progressively growing this plaques and calcifications and also clotting.

All of these things get, you know, accelerated by continuously the toxins off the smoke, right?

Cigareteette smoking.

And Dr. Raja you mentioned the blood goes back deoxygenated, back into the lungs and to the heart, you know, so they get oxygen.

Well, if your lungs are compromised or not functioning because you've lined them with this sludge from the smoking of nicotine, then you're not going to get that oxygenation at the highest level either in the blood going back.

So now you're now you're already starving your vessels also of oxygenation in your tissues, not getting it.

So you're causing that to happen as well.

Right.

So when you you know, when you talk about your asthma risk factors, there's not much different from patients with heart disease actually are the same thing.

The same disease.

Right.

Is a different progression.

But one thing important is that when somebody is diagnosed with peripheral arterial disease and if you follow them and I can give some statistics and this disease is more lethal than a breast cancer or a colon cancer, they're particularly people who end up losing their limbs.

Right.

Okay.

Or like you were telling me, you had an ABI, right.

In fact, that was nominated for.

Exactly.

So there are many studies done and the mortality or survival.

Right.

Related to the ABI's.

So let's talk specifically what that is.

So, ABI, is the ankle-brachial index.

Right?

Right.

So let's describe I just had my my one year once a year ago in I have a work up on everything and they're like, we're going to do an ABI on you.

I'm like, oh, okay.

You know, you just kind of go with what they say.

And so let's describe what that is.

Ankle brachial index.

So they're looking at the blood flow literally on my feet, that little soft spot in your ankles.

They have a little.

Julie, I'm going to have you explain that because you know how this goes down.

It's the first time I ever had one.

And I really because I knew I was doing the show this week, I thought, explain that to me.

So I was showing Julie my little graphic crafting.

It's very simple, actually.

It's it doesn't hurt.

It's not invasive at all.

It's just like a blood pressure thing.

It's a blood pressure cuff, essentially a blood pressure cuff put on your brachial up on the upper and then on your ankle.

Right.

And the pressures between are measured.

So it shows the flow and that depending on the levels of flow or the pressure that's within the artery, it tells us how well it's flowing.

So, for example, talk about the sorry, that's a simple way to put it, I guess, is yeah.

For example, when you check your blood pressure here, let's say it's in your 120 over 80.

Okay?

So that blood pressure should be everywhere in your body, heart pumps.

Now you check your blood pressure and in the leg, la caf letter caf, and it says 90 over 50.

Right.

So it's outcomes vary, but there's a blood pressure is high.

Yeah.

And a blood pressure which is low.

Something is not letting the blood go.

That's the blockage.

Yeah.

So then you make an index is the brachial pressure, peripheral pressure and you divide.

You should be one.

Mm.

Right.

100.

Now if it's 80 at the calf and 100 at the brachial.

So you have 80 divided by 100.

This is going to be point six or seven.

Right.

So usually if the ABI is less than 0.9.

Mm.

That's an indication of peripheral artery disease.

And so the interesting thing is you could not even feel anything going on lately.

And if you have and to your point, if you have an internist, your family doctor, how are you want to use the wording that proactively does this once a year?

That's great.

And so this is this is your chance to shine, Julie, Like do some advertising right here, man.

I would kiss every primary care family physician to do that because so many times it goes undetected right way too late until people are like, this is really bother me.

Wait until the toe is black or we wait until the pain is so bad that it's like people waiting on a heart attack.

And and this is I'm going to say this because everybody's familiar with it.

Time is muscle.

Okay.

Well, time is tissue in any fashion.

You don't get blood flow to an area.

The tissue dies.

Right.

That's heart brain and your legs and feet.

And we take our feet and legs for granted.

We they support us daily.

They walk us, they get us.

Plus it becomes debilitating.

People have to wait until they can't walk or go to work or they have so much pain.

Then they get in and we don't want them to wait till then.

We want them to be checked early on and have baselines.

Just like women going for mammograms.

We tell them at age 40, everybody at age 40 should be getting these tests.

This should be a gold standard.

So here's my just my reality check question to the world.

Right?

We we say this mammograms.

I feel marketing wise, prostate exams even marketing wise.

So we're not starting today, but let's make it more prevalent.

So this is something that you can ask for at, you know, an ABI.

Just think, hey, can you just check my the veins in my legs?

The reason I'm saying this out loud and being realistic is that when you're a patient that doesn't understand this world, which most of us don't, we're not in the medical world, how would one know to ask?

How would one know to get this checked?

And it's almost a question I'm asking hypothetically, but it's almost a way to educate the public.

And you said that earlier.

You're here to educate people, to tell them what to do, to advocate for themselves.

Yes.

So I am asking you just to go forward on that note.

Like realistically, people who are servers and restaurants, who are airline attendants, people who are on their feet all the time, construction workers on their feet, legs all the time, they're thinking, oh, I'm just tired.

You know, my legs are just tired.

But maybe it's more but maybe it's not.

And you know what?

I think we need to let everyone know it's okay to go to your doctor and ask for these things.

That's what they're doctors.

So therefore, they're there to provide care to them.

And too many times we trust the doctor to know everything and they're not going to.

So because they see a lot of patients they may not know your feet are getting tired or that you've been having some restlessness and you're sort of brushing it off.

I think it just if you're having any kind of questions, share it with your doctor there.

That's what they're there for.

Right.

And you need to advocate for yourself.

This is your body.

You need to be responsible for it and not expect others to always know what is best for you.

It's and I think the culture is very respective of professionals and to the point sometimes I think they forget they need to be respectful to themselves.

Right.

It's okay to ask your doctor that question.

You don't have to be all pass or nice.

No, we we have such a beautiful culture form like this little story real quick, because people, my kids all went away to school.

I'll miss it all came back.

Well are are coming in the process because you there's no place in the world like this place right.

And but that goes hand in hand.

They have a right to ask for that.

I want them to I want a feisty patient.

You know, I want somebody that's saying, wait a minute, you know, this is and that's what I'm there for.

I'm their voice.

So I'm being their voice.

Now you go out and you ask, Yeah, for these, you know, your baseline.

And it's just it's a point where your baseline changes just enough to where you get used to, what your new baseline is.

Don't get used to the new base.

No.

And it's and not a not all physicians are comfortable.

This is I know it's been going on for longer than we can say, but really it's new in a way as far as we're just getting to where we are pushing, really seeing the need to tell everybody and really reaching out, trying to get earlier detection and just really want people to understand that it's it's so important.

Right.

Let me put you other way.

Yeah.

Peripheral are like ABI.

You're talking to ABI.

It's just a simple test, right?

How important it is, let me tell you.

So when someone has an abnormal ABI and he or she is found to have peripheral arterial disease, so they have such a high incidence of heart dying, got strokes.

Mm hmm.

So many of them, they don't die of leg problem, right?

They die of a heart attack and a stroke.

So if they paid attention to the leg problem people.

So peripheral artery disease is an indication that this person has a high risk of having a heart attack and a stroke.

Right.

So American Heart Association, American Cardiology, College of Cardiology, if you look at the guidelines, recommendations, recommendation is any patient.

Anybody who has peripheral artery disease.

Right.

Should be treated as he or she's having a heart attack.

So.

Sure.

Aggressively.

Yeah.

There lies the next question.

How is this treated?

So we said in the beginning of the program, if we find this early enough, how do we treat PAD, PVD?

Well, obviously prevention, right?

Lifestyle always is always much, much better than when somebody already has a disease.

So somehow we lost a lot of time as far as treatment to start with.

Exactly.

Like we talk about heart disease, Right, Right.

Diet, exercise, diabetes.

So if we think of the the two main or two or three main factors for peripheral artery disease is diabetes.

I would say 95% of the people who end up having severe peripheral vascular disease and will talk about critical limb ischemia for our next question.

Yes, And they have diabetes, right.

And it's worse if they have a kidney disease and they're on dialysis and throw smoking.

So that's a perfect transition.

So talk about critical limb ischemia.

So that is part of what you do as part of your specialty.

These go hand in hand.

When does that become an issue?

Because then we're looking at also amputation, which is something that we have to address this evening.

It's always a little scary, but I think sometimes to scare people, not unrealistically scare them, but it's a thing.

I mean, this is where blood flow stops.

So let's talk about critical and ischemia and Dr. Raja just just throw that out there any way you'd like.

And then Julie, we're going to have you jump in here.

Right.

So the critical ischemia, if you have a continuation continue of... of this disease process, so starts with some blockages, which you don't feel anything, but you can pick up on ABIs Right?

Right.

But then if you continue, then the blockage gets worse, 70% or more that when you walk or do any physical activity where you leg muscles, they need more blood, You don't get it and you have become angina like a heart, right?

You have a pain in the leg, you stop, It goes away.

If you continue to do that, as you're saying, you start having this pain at rest right.

And then if the blockages are completely no, the main arteries are completely blocked, then you have some tiny collateral.

We call them tiny, tiny branches trying to get some blood down.

But it's not enough to have a tissue survive when when a patient gets to that point.

And I'm thinking about patients that don't either don't know or haven't sought help or treatment.

So how do you get to that point and how is your body?

And we say limb ischemia, right?

So I'm thinking arms and legs, but really it's mainly legs, if only legs.

So again, we're going back to signs and symptoms.

Are we talking about the same symptoms just just on steroids?

I mean, just like crazy to to make things more complicated, right?

Is that, as I said, majority of them have diabetes.

Right.

And as Julie was saying, they have diabetic neuropathy.

So what does that mean?

They can feel it.

Oh, goodness gracious.

Right.

Of course.

So they can have a severe blockages but they have no pain.

Mm.

They can.

The feet are numb, they can step on nail, they won't feel it unless until they see the foot and see there's an infection.

So you can have or they can have severe blocked arteries with no symptoms.

Mm hmm.

But only time when you hurt have a small injury to the toe or heel anywhere.

Now you need a lot of blood to heal.

Right?

And that's the problem.

They don't have it.

So the wound is never going to heal.

And I think that I'd like to, like, expand on that.

What a lot of people don't realize is when you don't when the blockage is significant.

Mm hmm.

It happens very rapidly in like 1 to 3 days.

The total can go from an affected to a black toe because.

Yeah.

And they can go to the next toe and I've, I've talked to people and they said this happened three days ago and it started out like a little blister or a little wound and then it progressed and their toes are purple and they're black.

And once they turn black, once the death of that cell happens, we can't recover that tissue.

So you've lost a toe?

Minimally.

I mean, that's it.

And I don't want to scare people from not going in because they don't want to probably go, you know, they might be afraid of what they'll hear, but you let that go on, you lose your leg.

Okay.

So I'm going to stop at a critical point here.

So you're talking once they get to a certain point, then two, three, four or five days later, blue toe, black toe, time to come off.

So let's talk about that.

That day or two or three prior to that middle point where three days later it's a dead toe.

What is happening those three days like what you said, a blister.

It can start simple as a blister.

It could be as simple as.

And the reason like a red spot, that's like the podiatrist removed the nail toenail, the tail falls off, the toenail comes off?

No.

And if there was some infection, let's say there was infection of the toenail and they removed the toenail usually just heals.

But this is never going to heal.

No, it's more intrusive.

So whatever small, any kind of injury, it's just not healing.

It's not because there's no blood.

Right.

I give an example of a plant.

If you don't put a water to the plant, no matter how spray shiny it looks, and pretty equal to nail polish, whatever.

But if there's no water, it's going to die.

Right.

So the problem of what we are talking about is the circulation, poor circulation.

It takes years to develop.

It doesn't the circulation, does it?

Now we do have events where they like if they have irregular heart rates and they've been diagnosed by their doctors with an irregular heart rate and they're being treated, there are chances that sometimes clots get thrown to the areas of their legs and stuff like that.

It can happen.

And that's an acute event.

So stop again.

So when they get thrown to your leg, like like they travel, it's like it's a traveling clot.

Okay.

And it closes.

That's a more acute event that will happen very suddenly.

The leg will leg or arm will go cold and it'll go very pale.

They may lose the ability to move it.

And you said it's numb, it's excruciating, it's excruciating pain and then goes numb.

Okay.

So that's the progression.

It's excruciating pain.

It's like a sudden, huge cramp, right to the calf, it doesn't go away.

Okay.

And it okay.

I've seen patients keep waiting and hoping the cramp goes away.

That's my question.

So you shouldn't wait.

If the cramp is not going away, there's a problem getting to the emergency room, Your doctor or emergency room.

It's not worth just waiting it out.

No, no, no, no.

Because, again, time is tissue.

Right.

And this is probably obviously not going to go away.

And it's only going to get worse.

So here's another question.

We were talking about neuropathy, right?

People going prior to this.

Now, before it becomes this cramp in excruciating pain when you can't, you know, knee's down, but everything's functioning.

It's like maybe it's muscle memory, it's your brain saying, okay, we'll move the ankle this way so that you can go up those stairs.

You can't feel it, but your body is somehow performing and walking up the stairs or walking.

So describe that differentiation now with a patient that's like, well, I can't really feel my toes, but everything work, everything's working fine, can't really feel my ankles, but I'm working fine.

And again, this is not someone who's in our world of knowing to look for that.

It's just that it'll go away.

Right.

And I think that one of the things that people need to be aware of, it's not as black and white with people with peripheral neuropathy.

It's various degrees.

Some people may just feel dull touch, but doesn't mean they don't have sensation.

Some don't have any to their feet, but they'll have it to their legs or it has progressed.

It depends on the person.

Okay, so there's varying degrees of that.

And not all diabetics have neuropathy have not progressed to that state or have that or anything goes long enough.

It will.

Is that what I'm hearing?

And then we definitely anybody with neuropathy have their circulation.

But because there is a part, we call it ischemic neuropathy, neuropathy related to lack of circulation, we won't know.

Is it just because of the diabetes affecting the nerve endings leading to these symptoms or there's a combination right?

So all of these patients actually the recommendation is anybody who has diabetes should have their circulation checked every year.

Right?

The reason is it's not that you have to have diabetes to have it checked either.

I mean, you know, for example, if you're feeling these symptoms and you're not diabetic and you know, you don't have to be diabetic.

Right.

And that's that's...

It happens to non diabetics.

We just happen to have a very large population of diabetes here.

Yeah, exactly.

Hundreds of several hundred thousand actually diagnosed diabetics in El Paso.

Right.

So I think the statistics in 2022 were over 300,000, 400,000 in our population.

That's more than a third.

Yes, our diabetic, very large population.

And that's the one that I have no ceases to amaze me to hear those numbers.

I mean, I know it I've been I've been doing the show for, again, 26 years.

It never ceases to amaze me that it's that high.

And any time I, I think most of us go into any kind of a medical situation on getting tested.

We always get tested for diabetes.

On that note, I do want to go into amputations.

And when does that occur?

Because if there's something we can do tonight, it scares people a little bit, but it's really informing them.

So we're talking about this neuropathy.

We're talking about, as you said, the blue or the black toe, and now that toes dead and now something needs to be done with it.

And so I hear often, not just toes, I hear often feet and then below the knee.

How does that get to a point?

How does peripheral artery disease get to a point where there are amputations and there's no easy way to say that?

But and and I'm asking both of you, whoever wants to jump in on the good doctor Raja.

Okay, Julie has a lot of experience with the this is extremely important question because there are different kinds of amputations, amputation of the toe amputation of the foot amputation of the entire leg.

Right.

And all of them have a huge difference in the consequences, the long term effects, right.

If someone has a CLI, meaning let's say one of the toes has critical limb ischemia has, a toe which has suddenly a blister, as Julie was saying.

We know it's black, right?

So the problem is not the toe, right.

Problem is the entire leg.

Right?

So there's blockages all over.

And this is basically like a tip of the iceberg.

Right now.

If some body does not understand that concept and have to amputate it, what's going to happen now?

You're developing a you're creating a huge wound that will never heal.

Right.

So when you talk to the diabetic, some of them, they have seen their grandparents and parents and they think maybe in diabetes, this is what happens.

You know, you have a toe removed and then half the foot is gone and just keeps going up and up and up.

That's because they were not completely treated.

It's a bigger problem.

Yeah.

Yes, much bigger problem.

The underlying problem, we're not we're not treating the cause.

We're treating the symptoms or the result of ...

It's like that Band-Aid theory ....

It when we talk about amputation, our goal is that how can we change a major amputation, which is below the knee or above the knee amputation to a minor amputation, which may be a tool or a few toes, Because if that heals, the goal is how you have a minor amputation.

But they heal, right?

So there's still they can wear their shoe.

They are more independ than they can walk and all that.

So that brings us to what we do, our critical limb ischemia program, which we have in Memorial Hospital.

Let's talk about that, because in my head I'm thinking, okay, yes, there's treatment, there's treatment, there's insulin, there's all kinds of diabetic treatment.

Then there's cardiology, lifestyle, etc..

But but the point where it's just the toe and then it becomes all the toes and then the foot, etc., etc., the whole body treatment.

And explain that to me.

And there's again, there's diabetes, there's some insulin, there's there's lifestyle changes.

But what do you see as treatment that actually works?

And let's say because I want to look at longevity here, let's say that there is a 25 year old and I get that.

That's young.

I do.

But we've 30.

Okay.

33.

So they've got 50 years still to live to be 80, which is really longer.

So how do we get this 25, 30 year old that now has a toe that's gone because of this issue and we want them to live to be 70 something?

What does he do?

He or she do going forward?

Following up with doctors, like what is that long term treatment?

See, Dr. Raja Dr. Julie.

I know.

Nurse Julie.

Sorry, but that's okay.

So to me, no, I think the key and one of the things that we really are proud of is a multidisciplinary approach, which means multitudes of people participate in that patient care.

And I know it's daunting because the patient's like, Oh my God, I got to go to three doctors now, but all of them are three double sets of eyes.

Hmm.

You know, their eyes on them.

So, for example, if they are being followed by a podiatrist, they have that toe.

They should be seeing a podiatrist after that regularly.

Maybe not, you know, weekly once it's healed, but every three months.

Usually the rule of thumb is two weeks, month, every three months, especially.

And then if there's wound care, should be faithful going to the wound care because it is they need to be patient.

It does take time.

Don't...one of the things that I've seen and I want to bring that up and just sort of interject because for the the people out there that do this, it's so important not to not to not quit going.

Once they start getting better, you know, they start seeing results.

It's almost healed and then they just don't show up anymore.

Well, then we see them six months later and it's worse because that's someone watching them.

They're giving them or they're ensuring that they're going in the right direction.

Following up with the cardiologist that opened up the arteries and irregularly seeing them, they also have ice on them.

They do regular ABI checks, not just yearly.

Once you've been diagnosed and you have a wound and there's been treatment, they follow more regularly and we can detect earlier on so that if a problem occurs, they find out internal infectious diseases.

Another big nephrology, you know, the doctors for renal disease, all these doctors that care for these patients and then their primary care is also optimal, another set of eyes to follow up with them regularly and keep track, make sure that their medications are appropriate, that they're working, or do we need to adjust them?

You know, that their studies are all being done.

Follow up is so important and I see so many times as it's been a year since they went back because they were getting better.

And now we have a mess they're in and they're sick and it's a mess.

And it just breaks my heart because it's like it could be.

Preventable.

Yes.

Why did you quit seeing your doctors?

Right.

So, you know, so that's where my quarterback.

Okay.

There you go.

That's you're the quarterback.

She makes it happen.

She makes sure that patient doesn't get lost.

Right.

She makes sure that they have appointment with all the physicians.

So this is a great segue into follow up care.

Right.

So we have a lot of this going on.

And and this is what's so great about systems, about programs.

It's not just you go the doctor and you're done.

So talk about the program that you all are in in the the follow up the CMS for the lack of a better word of your patients.

This series of patients need to follow up every two or three months.

The series needs six months.

How do you guys handle that and throw that out to the public that you're seeing?

When I say not the general public, but the public that has come in to have some kind of treatment.

So it starts from, let's say someone is ends up in the emergency room, let's say, or my office has a critical ischemia, the start from their worst of the worst, right?

First thing is diagnosis, right?

So once the patient gets admitted, same day, they get all tests done, arterial doppler, ABIs, all oxygen, saturation.

So we are doing everything quickly.

Within 24, 24 hours.

We have everything available to know what extent of this disease is.

I can tell you in the past, before this program, people can stay three or four days in the house before these things that are done.

So we are shortening all that time.

And then this next one more very important is vascular evaluation.

All right.

Which arteries blocked, how much is blocked, how far is it blocked?

So they have an angiogram done, which is more invasive, going inside, looking at arteries.

And then how can be opened that revascularization right.

That's the key to it re vascularized them right I like that wording to re vascularize them so we try to reverse as much as possible.

It could be endovascular by catheter based or by surgery, some bypass surgery or a together.

But you need a team to do that once we try to as complete as possible revascularization, which we are very proud of, you have all the technologies and everything available here and after that is okay.

Now revascularization is completed.

What is next, right?

So next we have I'm sure patient has the infection, so we need the best infectious disease physician patient has diabetes, probably control.

We need a good endocrinologist and podiatrist.

If someone needs amputation, we usually wait.

Let the blood go.

Let it heal and see how much tissue recovers once.

So expand on that.

So amputation.

So you're looking at letting re explain that when you're looking at the tissue amputation, you're trying to let some recovery happen before you amputate.

My right right.

So, yes.

Julie, do you want to jump in on that?

Look, I think that's so important to explain.

Yes.

And part of that is I think what a lot of people don't realize is like they may start with like a little piece of a black toe, but depending on how long they waited and I'm going to emphasize to you, do that again.

Yeah.

You don't always see all the damage.

And then once the blood flows to this area, that's when we know exactly what we're dealing with.

So it may be just a little tip of the toe and that'll be it.

It may heal because it was small, because that's not a lot or it may be more and not, you know, So that gives an idea so that they're not going through continuous procedures and other amputation.

Right.

So that's one is that's hard on the body.

Right.

These things are hard on people.

Is there ever a point where more is amputated than what needs to be at that moment?

Because there is the thought process of this is going to travel because the issue is not at a controllable state.

In other words, every amputation is, again, another shock on the system.

There are you know, is hate to say that some physicians still believe that, okay.

Or there's some indications that the concept is very strange.

But the concept is many people that think you have a toe or this gangrene, let's cut the leg off, problem is gone.

You know, like, okay, this is a bad leg, right?

First of all, it's not the leg.

Bad leg is never attached to a healthy patient person.

Right?

Right.

That's for sure.

Right.

Okay.

Right, right.

So if you look at the data of people who undergo undergo amputation, major amputation, 25% are dead within a year and 60% are dead in three years, worse than a cancer.

So you are not doing a favor to a person advising them to have an amputation.

Right?

Exactly.

It's not about the leg.

It's not the solution.

It's the entire body.

It's the entire body.

God, there's anything that we're going to get across the night.

And so we're at that eight minute point where I was kind of talking about this is where all comes together.

And Julia, I'll start with you.

But again, both of you, let's talk about something either that we've already talked about, we really want to emphasize, which is this or something that we haven't talked about yet that you really want to get across this evening.

Just don't wait it.

You know, there is no joke.

There is not a bad, stupid person if it's critical getting into the emergency room.

I'd rather them come to the emergency room, get checked or seen or get into their physician immediately, get seen them wait and have damage and end up with an amputation.

We really don't like to see that it it happens.

Right.

And it's necessary at times, but we make sure that's another part of this is we everyone, you know, gets looked at by multitudes of physicians.

And so there's multiple eyes on it to ensure that we everything has been done to prevent that.

But there are cases that happen when it's been goes too long and there's no other solution.

But we really don't want to see that.

That's really if that's the case.

And I think you hit the nail on the head and I'm saying this too, because again, realistically, not everyone has a primary physician.

Not everybody has their internist, Right.

So clearly the emergency room.

Yes, exactly.

And yes, I mean, if that's the least they can do..

Right.

We live in that world.

But if not, do that and, you know, it was it's an old philosophy.

It's that's why we want everybody to be aware of this is we used to do a lot of things.

We used to cut off the breast and now they do lumpectomies, right?

We amputations the same thing.

We used to just remove of the source and think that that's going to fix everything, but it's not the reason that it's occurring.

Same with everything else.

You have to look at the whole picture exactly.

Nicely explained Dr. Raja.

So I would emphasize on two things.

First of all, the first thing very important is prevention.

So I think our primary care physicians, I would strongly recommend that they see the patient's foot get the socks off this, if there's any sores, things like that, and then do a basic ABI studies, because that's going to be exactly what ABI is for.

Those are just tuned in is ankle brachial index, very simple blood pressure in the legs, arms and very, very helpful.

Now, unfortunately, if somebody has gone to a stage where they already have a gangrene, toe or heel or something, Please look for places who specialize in this disease process.

If somebody or physicians tells you that you need a major amputation, get a second opinion.

This is extremely important.

As Julie was saying, in Hispanic culture, they put their physician doctors very high and whatever they say, this is it.

Right?

But sometimes it's just unawareness, not being aware of particularly elderly patients, their sons, daughters or grandchildren.

We like to educate them.

It's very simple to Google.

Yeah, CLS specialists.

Who's the one who's doing all this?

What is the data you can look at?

The data is open knowledge.

What is the percentage of amputation in which hospital?

If one hospital has a 15% and other patient other hospital has a 3%, you know, that hospital is doing something different, right?

You go over there.

Yeah.

So that's where Dr. Google comes in.

So we joke about it and there's good educators.

But yes, we can educate ourselves.

So when they do Google, I want to just let everybody be aware because I think it's a good point.

Actually, a patient told me this is they weren't aware cardiologists took care of the legs.

Oh, you know what?

That's a good point.

They think your heart my like stung.

Exactly.

So I want you know, people to be aware when you Google those doctors, there's many cardiologists that do vascular.

Yeah.

And that is a cardiologist, Interventionalists.

Right.

It's an artery.

And they also do the veins, the DVT and the, you know, what we call deep vein thrombosis with clots in the legs.

So talk about that at all times.

But just sort of skirting because we might mainly focus on the peripheral artery disease.

So but it's still there that they do treat that.

So don't discount.

You know, another thing, too, is if you're a primary physician or your family doctor does not have the capability of doing ankle brachial indexes.

Right.

Because that is a trained.

It is even though it's very simple.

We make it sound simple, but it it does require training and certification.

You can order it at facilities to do that as an outpatient so they can ask their doctor, okay, you don't do it.

Will you please order me to go get the studies done at facilities to do it?

So these will be facilities that are blood taking for facilities, for example, or I'm not sure about how many clinics and things do that.

I do know that the hospitals, hospitals that do do okay.

And it is like I said, I just had one last week and it really is a blood pressure cuff on your legs.

We are at 2 minutes, so I need a wind it down.

This is really is that lightning round?

If there's anything else that you want to say, if not, we'll let people know where they can watch the show again.

In case you didn't catch us all.

Anything else you want throughout the real quick?

No, I think again, prevention is the most important part.

And early detection.

Early detection.

And you're not too... We say over 40, but, you know, if you have a history... if you are a brittle diabetic, when I say that, you've had it since childhood and you have a family history of all this that's severe and you know, dad and you have these...go, you know, or any kind of symptoms, you know, things, questions, that's what they're they're, you know, exactly your, for example, it is your right.

It is your body.

Please advocate for yourself.

Please.

We're here to let you.

Yeah.

It's never be embarrassed to ask questions and advocate for your, you know, never.

There's never a stupid question, right?

No.

Julie Berumen, a nurse who is the patient navigator at the hospitals of Providence at the Memorial campus.

Again, Dr. Raja, Quarterback I love that for the SEAL program.

Dr. Laiq Raja, thank you again.

Interventionist... Interventional Cardiologist.

Again, The Hospitals of Providence.

We can't thank you enough for being here so much.

If you did not watch this entire show or if you'd like to watch it again or any of the other topics that you've seen here on The El Paso physician, there are several places you can go to do that.

One is PBSelpaso.org Just look for the words The El Paso Physician.

You can also go to the El Paso County Medical Society's website, and that is EPCMS is just think of the acronym for that EPCMS.com and that what everybody's doing these days is good old fashioned YouTube.

I'm Kathrin Berg and you've been tuned in to The El Paso Physician.