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Hi, Doctor Palto here. 
I want to go a little bit over 

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the DME products. 
DME means durable medical 

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equipment that are non custom 
that we have in the office and 

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this is going to be for the 
staff just to understand a 

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little bit about these products.
And yeah, so a few things to 

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know. 
Durable medical equipment is 

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something that's not specific to
a Podiatry office. 

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It's something that we offer 
patients more for convenience 

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because the more places that we 
have our patients go, the more 

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challenging it is. 
If we have them go to, for 

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example, an outside vendor like 
Hangar, it has to make an 

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appointment. 
They have to be seen. 

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They have to be fit. 
There are some doctors that have

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them go out for walking boots 
and for other things like that. 

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It's a little bit of a hassle 
having it in the office. 

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But in the long run, I think our
patients get better care with 

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that. 
They are usually covered by 

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insurance. 
What we're finding now is some 

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patients depending on their 
deductibles they may even look 

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for it on Amazon. 
It's not something that we 

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actively encourage, but some 
patients do that to see well 

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what would be on Amazon for a 
similar product it it can go to 

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the deductible. 
So for some patients they might 

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be quite expensive for some of 
these products. 

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But for the majority of patients
it's it's pretty much well 

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received and we do a lot of it. 
If they have Medicare, I would 

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just remind you to check same 
and similar those are meaning if

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they've had a device within five
years, that's kind of the the 

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lifespan of most of these 
products. 

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And if something else changes 
like the severity of the 

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condition changes or like their 
leg changes, the form of the 

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leg, the swelling, things like 
that, that the previous one 

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couldn't fit or if it's a new 
condition, those are all kind of

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reasons or if it gets lost or 
eaten by their dog or something 

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else like that. 
They have to fill out some forms

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and I'll give you some examples 
of those forms as well here. 

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So what we have here in the 
office, we have a collagen wound

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dressing. 
We have an ankle brace called 

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the Exoform. 
We have a walking boot, a tall 

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and a short night splint, A 
surgical shoe, surgical shoe 

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with peg assist offloading 
insole and A and A and a 

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velocity brace. 
So I'm going to go over those 

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today. 
Those are the most common DME 

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items that we have here in the 
office. 

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There's something that needs to 
be filled out every time we see.

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It's called proof of delivery, 
So DME durable medical 

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equipment, proof of delivery. 
This needs to be signed saying 

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that they got them, that they 
were in good condition, that we 

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can build the insurance and if 
they're custom made that we 

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can't return them. 
OK, if they're non custom we 

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can, but if they're custom we 
can't. 

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So these are some of the custom 
ones we have for DMV forms. 

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There are other ones for non 
custom. 

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So this one has, you can see the
braces, it also has the Cam, 

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boot, night, splint, things like
that, has the quantity right and

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left of kind of what they're 
getting. 

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So we're going to go over a lot 
of these, these devices. 

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So first of all, let's talk 
about AMAREX. 

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AMAREX has a number of products 
that we carry in the office such

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as Amira Gel Red and Amira Gel 
Blue. 

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Those creams, these are the 
wound care kits that we use 

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called Helix, which is a 
collagen, A collagen powder. 

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So if you look at it, it's a 
powder, there's gauze 2 by two 

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gauze and there is some 
bordered, bordered gauze. 

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So we do the bordered gauze and 
the collagen, that's the one 

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that we tend to do. 
It can either be a 15 or 30 day 

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supply. 
It helps to heal ulcers. 

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You have to make sure that 
they're not getting VNA or 

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visiting nurses or home health 
because if they do that these 

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programs, they have to cover all
the dressings as well for their 

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care. 
So we cannot have a patient 

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getting home health get this, 
otherwise insurance won't cover 

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it. 
What we sometimes do is we give 

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them enough for 15 or 30 days 
and then we send them to 

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visiting nurses or VN as or home
health. 

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We order that for them, in which
case they're happy because it 

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doesn't have to come out of 
their their funds that they get 

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to take care of the patient. 
We usually do it for 15 or 30 

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days. 
I tend to do 15 days until it 

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looks like it's doing really 
well. 

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Then I might do 30 just because 
I'm usually having to evaluate 

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that ulcer. 
You apply one pack per day, so 

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they come in these little 
individual packs. 

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You apply water or saline. 
This comes with a saline spray 

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in there. 
And then you mix it with the 

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collagen and use a tongue 
depressor to put it on the wound

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and you cover it with a 
secondary dressing. 

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So here's an example of using a 
tongue depressor to put it on 

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the ulcer. 
This is exactly what we would 

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do. 
And then you would put on the 

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border to gauze the secondary 
dressing on it. 

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So you do the wound spray to 
kind of clean it off and then 

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you do the the, the collagen 
inside of there, see how you get

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it wet. 
So with this, each one of these 

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is made for one day, so they'll 
get thirty of those per day. 

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So that kind of goes on. 
And then you use the the 

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secondary dressing that goes on 
top of it for the patient. 

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This is an example of the gauze 
that's stuck on. 

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We have the border gauze here in
the office. 

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Here's the DME sheets for the 
collagen. 

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So there are a lot of different 
devices and wound care things 

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that they carry. 
We do this, this 15, this 30 day

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supply with the bordered gauze 
or this 15 with bordered gauze. 

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Now there are other things that 
they have, they have rolled 

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gauze. 
They also have other things that

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are not collagen. 
They have calcium alginate and 

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other types of things foam. 
So foams tend to be more for 

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draining wounds. 
We don't see a lot of those that

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are like venous stasis ulcers 
that are draining a lot. 

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We don't see a lot of those. 
We'll put like a una boot on and

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then the calcium alginate might 
be a kind of a more of a 

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draining wound as well or kind 
of an infected wound. 

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For that we usually use like 
Betadine or we're going to use 

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like an Amerigel Red on those. 
OK This is an example of whether

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DME or durable medical equipment
item, it's a, it's an ankle 

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brace or an extra form brace it 
can be. 

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So usually when we see a really 
bad sprain we'll get an X-ray. 

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Initially we might put them in 
an UN boot and a Cam boot to 

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really kind of rest rest the 
foot and then you transition 

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them to this ankle brace or this
Exiform brace at at the two week

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follow up if there's no fracture
and then after the ankle brace 

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then we'll transition to them to
a compression sleeve. 

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So those are that's kind of how 
we transition. 

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And then occasionally for a 
really bad ankle sprain, we may 

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do some shockwave to help get 
down the swelling and help speed

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up the recovery for the ankle. 
Here is an example of a walking 

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boot. 
There are tall and short ones. 

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I want to kind of explain the 
difference. 

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The tall one goes up a lot 
higher. 

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It's used if someone has an A 
fibula fracture or an ankle 

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fracture or a post op of a 
fusion or a big surgery, a 

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bigger surgery, they're going to
get the tall boots patients that

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tend to transition out of casts,
they're more frequent to get it 

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the tall boot or a tendon issue.
So if the tendon is up here, 

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even though it affects the 
bottom of the foot, if we want 

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to immobilize the peroneal 
tendon, the posterior tibial 

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tendon, or the Achilles tendon, 
we might put them in a in a 

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bigger boot. 
Also, if they're getting that 

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Achilles lift thing that we 
talked about before that to lift

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up to reduce the pull on the 
Achilles for Achilles tear or 

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Achilles surgery, you might use 
a taller boot like this. 

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It moves the pressure to the 
lower lower leg and ankle, and 

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moves it moves the pressure away
from the lower leg and ankle by 

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putting the pressure up here, 
the short one. 

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Another type of boot that we do,
It's used for foot and ankle 

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issues. 
It's not usually used for bigger

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ankle fractures because you want
more protection up top, used 

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after typical bunion surgery and
hammer toe surgery. 

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And also it's better for shorter
patients that have a shorter 

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leg. 
And also for amnio patients, 

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we're doing an amnio then we can
do this for patients as well 

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after the amnio to kind of 
protect that area. 

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This is a night splint. 
So the night splint is something

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that we use very frequently in 
the office. 

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It's used to treat Achilles 
tendonitis and Aquinas. 

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So Aquinas just means tightness 
in the calf and we don't 

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primarily use it. 
And I'll explain that not 

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specific to plantar fasciitis. 
Plantar fasciitis is in the 

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bottom. 
But secondarily, most of these 

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patients have tightness in the 
calf, which is Aquinas, and this

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is used to to to loosen the calf
along with foam rolling and the 

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morning stretch. 
Like I said here, there are some

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Velcro side straps right here 
that can be tightened or 

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loosened here on the side. 
So that's something we want to 

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teach patients when we're giving
it to them, these side straps. 

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Also there are some straps that 
can be tightened or loosened 

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here to keep their heel down. 
If these are too tight, it could

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cause some numbness in the foot.
And there's also a cheese wedge,

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which is right here, this cheese
wedge that can be pulled out if 

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there's some discomfort or 
numbness in the toes. 

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Other common options would be 
something called an anterior 

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night splint, which is a splint 
that goes in the front of the 

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foot. 
We do not have those in the 

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office. 
Or a sock called a Strasburg 

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sock, which is a sock that goes 
around the toes and the foot and

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then pulls things up. 
Those tend to make things pretty

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numb as well, so just be aware 
of toe numbness and pain. 

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That's pretty common. 
Most patients can't wear this 

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all night long. 
I tend to recommend I call it a 

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stretch splint instead of a 
night splint. 

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So a stretch splint, They're 
wearing it for three hours a 

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day. 
And if they have issues on both 

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feet, you're going to use it on 
the right foot one night and the

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left foot the other night. 
So they kind of alternate very 

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rarely doing to give to give 
both or bilateral night splints.

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And another thing, they're not 
supposed to walk with them. 

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They have a tread in the bottom,
but the tread isn't to walk on. 

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So just be aware of that. 
Here's some examples of surgical

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shoes. 
The only surgical shoe we have 

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in the office is this top one. 
This is the traditional flat 

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surgical shoe. 
Ours have open toes. 

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This is just kind of an example.
There's two straps. 

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Be careful where the straps hit 
based on where the wound is. 

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Sometimes the IT may hit the 
area of the wound or the ulcer 

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that the patient has. 
Can be used for wounds, can be 

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used for fractures, for painful 
feet, for infections. 

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But you don't want someone to be
in a shoe or ulcers. 

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This is an example of an ortho 
wedge shoe. 

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If you've heard this, it's used 
to offload the front of the foot

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so you can see it has a heel on 
it but no front of the foot. 

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So as they're walking you have 
to be careful of balance, but it

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just puts pressure on the heel 
and then not on the front. 

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And then there's something 
called reverse ortho wedge, 

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which uses is used to offload 
the heel. 

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So you had only puts pressure on
the front and takes pressure off

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the heel. 
That's for heel ulcers as well. 

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And then in conjunction with 
that surgical shoe, there's 

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something called a peg assist, 
which is this thing, it's a, 

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it's a, it's a peg assist, it's 
a pegs, they called pegs right 

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here. 
It's used to offload painful 

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foot areas specifically. 
We use it a lot to offload 

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ulcers or infections or areas. 
You mark the area with lipstick 

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and then you take out the pegs 
in that area. 

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It's not usually covered by 
insurance. 

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It's reasonable. 
There are instructions here if 

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you want to look at it. 
Here's a little a little video 

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that kind of explains if there's
an ulcer let's say on the first 

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met head you you mark it with a 
with like a a marking. 

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What's that? 
A lipstick. 

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You mark it with lipstick and 
then you take the the liner and 

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and most of these surgical shoes
have a a liner area that that 

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the bed comes out and you put in
this peg assist and then what 

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they do is they they stand on 
that area where and it makes it 

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it kind of transfers where the 
where the high pressure area so 

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they step on there and it 
transfers where the ulcer is 

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with this area of the lipstick 
and it and it transfers it on 

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there And then what you do is 
this area you you take it out 

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and you push out the pegs in 
that area. 

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So that's the high pressure 
area. 

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You kind of pull it out, you you
remove the black pegs that are 

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underneath it, so you can see it
here, it's marked and then you 

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just kind of flip it around and 
you push those, push those out 

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on the other side. 
And then there's also, so in the

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past we we've done this, but now
they added something to this 

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where there's a another sheet 
that goes in the bottom. 

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So once you get everything out 
and that's going to offload it 

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without allowing things to drop 
down. 

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We used to use a lot of felted 
foam and so you put the foam on 

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the top and the felt underneath 
and this is just kind of a kind 

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of a speedier way of doing this.
And then there's another kind of

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a stabilizing board because what
happens to ours is that the, the

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ulcer can suck through that 
hole. 

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It can kind of like drop down 
and it can spread things out. 

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So this kind of stabilizes it in
the, in the surgical shoe for 

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that type of a patient. 
This is something called a 

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velocity brace. 
So a velocity brace is basically

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an A non custom AFO. 
So we use a lot of Afos that'll 

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be in the other lecture, but 
it's a non custom. 

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AFO helps reduce frontal plane 
rotation. 

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Frontal plane is this plane 
right here. 

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So the the front of it, so 
either pronation or supination 

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or flattening of the foot. 
You could think of it that way. 

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It prevents that, doesn't allow 
it to flatten in because it has 

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these stirrups on the side. 
It's very good for ankle sprains

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or flat feet, for posterior 
tibial tendonitis or tendon 

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dysfunction and for Achilles 
tendonitis that's made worse by 

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flattening of the foot. 
The neat thing about this is you

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can heat mold them, this little 
arch support here, you can put a

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little heat, heat it up there 
and there's instructions right 

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here as well. 
So those are the non custom DME 

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items. 
The next things we're going to 

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go over are the more custom 
ones.