1 00:00:04,000 --> 00:00:07,680 Hi, Doctor Felter here again. This is Part 2 in the procedures 2 00:00:07,680 --> 00:00:11,040 that we do in the office. This is a staff training course. 3 00:00:12,240 --> 00:00:15,560 I'm going to talk a little bit now about carry Flex. 4 00:00:17,080 --> 00:00:20,520 So carry flex is a procedure that we do in the office. 5 00:00:20,800 --> 00:00:24,120 It's used to help with detached or thickened toenails. 6 00:00:24,120 --> 00:00:27,840 So for example, if there's a thickened fungal toenail, it 7 00:00:27,840 --> 00:00:29,280 works very well for a thick and toenail. 8 00:00:29,560 --> 00:00:33,040 The ones that it works the best for are those toenails that only 9 00:00:33,040 --> 00:00:36,160 have a little bit on the base. If they only have a little bit 10 00:00:36,160 --> 00:00:39,200 on the base and the rest of it's not, not present or detached or 11 00:00:39,200 --> 00:00:40,600 fungal works really well for that. 12 00:00:41,000 --> 00:00:48,200 Or a nail that has a a lot of they've had a previous like 13 00:00:48,200 --> 00:00:51,280 ingrown toenail procedure and it and it hasn't worked and the 14 00:00:51,280 --> 00:00:53,680 nail looks very narrow so it works very well for that. 15 00:00:54,400 --> 00:00:57,000 The process is you first grind down the nail with one of the 16 00:00:57,000 --> 00:00:58,280 grinders. This is the only thing that we 17 00:00:58,280 --> 00:01:01,800 really grind in our practice are are the carry flex nails. 18 00:01:02,360 --> 00:01:05,519 You apply something called the bonding agent, which is a liquid 19 00:01:05,519 --> 00:01:09,600 that you put on the nail and then you you let that dry for 20 00:01:09,600 --> 00:01:11,560 about 30 seconds. Then you apply a coat of the 21 00:01:11,560 --> 00:01:17,360 carry flex, the carry flex, you apply it a light layer 1st and 22 00:01:17,360 --> 00:01:21,640 then you do the UV light for like 30 seconds just to harden 23 00:01:21,640 --> 00:01:24,520 it up a little bit and then you do it another piece. 24 00:01:24,520 --> 00:01:26,640 And then once you're done you then you do 2 minutes. 25 00:01:26,680 --> 00:01:28,600 OK, so 2 minutes is when you do the final amount. 26 00:01:28,840 --> 00:01:31,880 So you tend to do a layer over then like initial layer. 27 00:01:32,520 --> 00:01:35,080 And then the reason you use the the UV light is so it doesn't 28 00:01:35,080 --> 00:01:38,200 it's too flexible it it moves around, it's kind of like watery 29 00:01:38,200 --> 00:01:40,720 ish. And then you apply it again 30 00:01:40,720 --> 00:01:42,920 until you're done. And then when you're done you 31 00:01:42,920 --> 00:01:45,680 you cure it for 2 minutes and then you buff the nail. 32 00:01:45,680 --> 00:01:51,840 Usually I buff it with a there's a a file that's in there to buff 33 00:01:51,840 --> 00:01:53,720 it down. If it's really thick, you can 34 00:01:53,720 --> 00:01:56,840 use the Dremel again and then you do the sealant, there's a 35 00:01:56,840 --> 00:01:59,360 sealant on there. You do that for and then you 36 00:01:59,600 --> 00:02:03,040 cure it for 2 minutes and then the patient's all set with that. 37 00:02:03,920 --> 00:02:07,920 You have to remember to apply the the Cariflex a piece at a 38 00:02:07,920 --> 00:02:09,440 time and may not make it too thick. 39 00:02:09,800 --> 00:02:12,840 And then I always say for patients, they usually come in 40 00:02:12,840 --> 00:02:15,240 in the spring to do it, unless they're going on a vacation in 41 00:02:15,240 --> 00:02:16,440 the winter. So if they want it in the 42 00:02:16,440 --> 00:02:19,760 winter, then they can come in in the winter, but usually they 43 00:02:19,760 --> 00:02:22,960 come in in the spring for it. And then it lasts about 3 44 00:02:22,960 --> 00:02:25,160 months. What you'll find with the nails 45 00:02:25,160 --> 00:02:29,000 is that if the nail grows, if it doesn't grow out, it grows 46 00:02:29,000 --> 00:02:30,960 thick. And so if it grows thick, it's 47 00:02:30,960 --> 00:02:33,120 going to be, it's going to be lifted at the base of the nail. 48 00:02:33,120 --> 00:02:35,600 So they may come in to have a change just because it lifts up 49 00:02:36,080 --> 00:02:38,280 in the back because a lot of these thickened Toen nails 50 00:02:38,280 --> 00:02:41,480 instead of growing long, they'll grow thicker, OK. 51 00:02:41,480 --> 00:02:45,960 So it's something that patients really enjoy and works really 52 00:02:45,960 --> 00:02:48,480 well for their, for their nails. With our office, they tend to 53 00:02:48,480 --> 00:02:53,240 buy the kit and they keep the kit we charge usually increased 54 00:02:53,240 --> 00:02:55,920 price for the first nail and then less for the additional 55 00:02:55,920 --> 00:02:59,760 nails. This is an example of Lunila 56 00:02:59,760 --> 00:03:03,280 Laser. Lunila, we've had a couple of 57 00:03:03,280 --> 00:03:05,440 different types of lasers in our office. 58 00:03:05,440 --> 00:03:07,640 We have the Qterra laser, which is the one that we typically use 59 00:03:07,640 --> 00:03:12,560 for warts and we have a Remy laser and we also have a Luna 60 00:03:12,560 --> 00:03:14,520 laser. So the Luna is the one that's a 61 00:03:14,520 --> 00:03:17,640 box and you put your foot in the box and you and you turn it on. 62 00:03:18,160 --> 00:03:22,040 Now if you look at these pictures, these are the nails 63 00:03:22,040 --> 00:03:24,440 that it works better for. So what what what's the 64 00:03:24,440 --> 00:03:27,080 difference between this and a lot of the other ones we see, 65 00:03:27,400 --> 00:03:32,800 these are normal thickness nails that are a little bit lytic at 66 00:03:32,800 --> 00:03:35,200 the end. So lytic means it's detached. 67 00:03:35,600 --> 00:03:38,160 OK, see how it's detached and there's some fungus underneath 68 00:03:38,160 --> 00:03:39,840 the tip. But if you notice all of these 69 00:03:39,840 --> 00:03:42,000 nails, they're they're not very thick. 70 00:03:42,520 --> 00:03:45,680 The challenge with laser, laser does not work very well with 71 00:03:45,680 --> 00:03:49,920 very, very thick nails. It works OK with these nails 72 00:03:49,920 --> 00:03:53,280 that are a little bit lytic or detached and have a fungus in 73 00:03:53,280 --> 00:03:54,920 them. So that's the main key if you're 74 00:03:55,000 --> 00:03:58,520 looking at like what's the kind of the, the selection process 75 00:03:58,520 --> 00:04:01,920 for who does the laser, It would be those types of patients that 76 00:04:02,240 --> 00:04:04,720 have less thick nails. Otherwise, we're tending to do 77 00:04:05,840 --> 00:04:07,960 the oral medications. The topicals aren't all out 78 00:04:07,960 --> 00:04:09,720 effective, so once again works better. 79 00:04:09,720 --> 00:04:12,960 For lytic nails. I recommend getting a nail 80 00:04:12,960 --> 00:04:15,640 sample prior to starting the the treatment. 81 00:04:17,880 --> 00:04:20,160 Oral medication versus laser, you have to have that 82 00:04:20,519 --> 00:04:23,280 conversation with the patient if you're wanting to prevent 83 00:04:23,280 --> 00:04:25,240 recurrence. There's two things that you can 84 00:04:25,240 --> 00:04:28,080 do certainly. I guess the main issue with 85 00:04:28,120 --> 00:04:31,360 patients I explains that the problem is is incomplete cure 86 00:04:31,360 --> 00:04:33,960 usually, and it's not really recurrence. 87 00:04:33,960 --> 00:04:36,760 Incomplete cure is because they're they they don't take it 88 00:04:37,080 --> 00:04:39,040 long enough, especially like the oral medications. 89 00:04:40,080 --> 00:04:42,320 I like to have the until the nail is normalized, they're 90 00:04:42,320 --> 00:04:44,880 actually on something. So in terms of the the laser, 91 00:04:44,880 --> 00:04:47,600 one of the challenges is if when they're using it it's not 92 00:04:47,600 --> 00:04:50,000 totally grown out, there's a chance that it could regrow in 93 00:04:50,200 --> 00:04:53,200 that that's the incomplete cure component but it can also come 94 00:04:53,200 --> 00:04:55,240 back from the fungus that can live in their shoes. 95 00:04:55,480 --> 00:04:58,120 So we have something called mycomist which is spray that can 96 00:04:58,120 --> 00:05:02,160 go in the shoes. We also have shoe ZAP, which is 97 00:05:02,160 --> 00:05:04,760 used to prevent recurrence, which is ultraviolet light that 98 00:05:04,760 --> 00:05:06,360 kills the fungus that's inside of the shoe. 99 00:05:06,360 --> 00:05:08,000 So patients are concerned about the shoes. 100 00:05:09,080 --> 00:05:11,640 I would just say that all fungal nail treatments take one year to 101 00:05:11,640 --> 00:05:15,080 see final results because a new nail needs to grow out. 102 00:05:15,160 --> 00:05:20,120 I say that Lamisil is about 80% effective, Luna is about 60% 103 00:05:20,440 --> 00:05:22,400 based on the on the nail, right. If you have these really 104 00:05:22,400 --> 00:05:25,400 thickened toenails, Luna isn't going to penetrate enough and 105 00:05:25,400 --> 00:05:28,760 the topical are about 2020% effective and I'll require 106 00:05:29,000 --> 00:05:31,480 treatment to prevent recurrence. The other thing I use for 107 00:05:31,480 --> 00:05:34,960 recurrence to prevent recurrence is I use once they're totally 108 00:05:34,960 --> 00:05:40,160 better, using a topical antifungal once a week on the 109 00:05:40,160 --> 00:05:43,920 skin and I do that. That would be like after it's 110 00:05:43,920 --> 00:05:47,720 totally gone and and that's only because many times the the the 111 00:05:47,720 --> 00:05:53,440 nail fungus can start from the skin fungus nail plate avulsion. 112 00:05:53,920 --> 00:05:56,720 This is an example of something that we do if someone has a a 113 00:05:56,720 --> 00:06:00,680 very painful ingrown toenail and they don't want to just take the 114 00:06:00,680 --> 00:06:03,440 sides out or if they have a very thick nail or if they have maybe 115 00:06:03,440 --> 00:06:05,680 blood underneath the nail, you can remove it. 116 00:06:05,680 --> 00:06:08,880 Here's an example of a nail that was kind of detached at the 117 00:06:08,880 --> 00:06:10,600 base. Sometimes these these nails, 118 00:06:10,600 --> 00:06:14,080 they get injured at the base and they get kind of elevated and 119 00:06:14,320 --> 00:06:17,360 we'll call it boggy, which is like there's drainage in there 120 00:06:17,360 --> 00:06:19,400 and it's kind of detached and lifted. 121 00:06:19,400 --> 00:06:21,640 It's almost as if someone put something underneath there and 122 00:06:21,640 --> 00:06:24,000 it's kind of pulling it up and it was almost lifted up. 123 00:06:24,000 --> 00:06:26,320 What's holding it in most likely is just the edges. 124 00:06:26,560 --> 00:06:27,960 So for this we always numb it up. 125 00:06:28,160 --> 00:06:31,200 The only reason we wouldn't numb it up if if someone is has 126 00:06:31,200 --> 00:06:34,400 neuropathy, but most of these patients we numb up. 127 00:06:34,640 --> 00:06:36,080 We don't use this type of a tourniquet. 128 00:06:36,080 --> 00:06:37,880 This is the old type of tourniquet for the picture I 129 00:06:37,880 --> 00:06:40,040 got. We usually use the little green 130 00:06:40,040 --> 00:06:43,480 ones that we put on the toes and then they'll stop the blood 131 00:06:43,480 --> 00:06:44,640 supply if you if you didn't know. 132 00:06:44,640 --> 00:06:45,800 That's why we put those on there. 133 00:06:46,040 --> 00:06:49,320 So you you roll it, you roll it up on the toe and then as it as 134 00:06:49,320 --> 00:06:52,640 it as it rolls up it actually pushes the blood out and then 135 00:06:52,800 --> 00:06:56,200 this is the the nail base. It's used for a very loose nail 136 00:06:56,200 --> 00:06:58,760 also for something called the subungual hematoma, which is 137 00:06:58,760 --> 00:07:03,040 blood underneath the nail. It can be for a nail avulsion, 138 00:07:03,040 --> 00:07:04,480 which just means pulling off the nail. 139 00:07:04,480 --> 00:07:06,880 It can be total, meaning you take the whole nail off or 140 00:07:06,880 --> 00:07:09,880 partial, which is mean you just take off a side of the nail. 141 00:07:10,960 --> 00:07:13,760 A lot of things like the the staff, sometimes you you're 142 00:07:13,840 --> 00:07:18,000 you're wondering well what's an I and D what's an avulsion for? 143 00:07:18,000 --> 00:07:20,960 For the staff purposes I'll explain the difference. 144 00:07:20,960 --> 00:07:24,320 But an avulsion if you take the whole thing off as a total nail 145 00:07:24,320 --> 00:07:27,160 avulsion, if you take an edge out, it's a partial nail 146 00:07:27,160 --> 00:07:29,000 avulsion because you're an impartial of the nail. 147 00:07:29,320 --> 00:07:33,000 Now if there's an infection in there, the same partial nail 148 00:07:33,000 --> 00:07:34,840 avulsion is called an incision and drainage. 149 00:07:34,840 --> 00:07:37,040 And the reason it's called you're incising it and you're 150 00:07:37,040 --> 00:07:39,440 cutting it and you're draining out the infection that's usually 151 00:07:39,440 --> 00:07:42,280 in there. The the difference is if there 152 00:07:42,280 --> 00:07:44,960 is redness on the side, if there's pus things like that, 153 00:07:44,960 --> 00:07:47,000 that's that's considered an incision and drainage. 154 00:07:47,240 --> 00:07:49,680 The setup for for the staff is all really the same. 155 00:07:49,680 --> 00:07:52,960 The only difference up is that if you're pulling totally the 156 00:07:52,960 --> 00:07:56,040 nail off, a lot of us like to use some adaptic because this 157 00:07:56,040 --> 00:08:00,320 can can when you pull up the bandage, you can stick the the 158 00:08:00,320 --> 00:08:03,000 gauze, little fibers get stuck in there and that's a challenge 159 00:08:03,000 --> 00:08:04,680 for them. And so our patients, they tend 160 00:08:04,680 --> 00:08:06,280 to soak before they take this off. 161 00:08:06,280 --> 00:08:08,920 And if you're doing a total nail, we'll do that adaptic, 162 00:08:09,440 --> 00:08:12,800 apply sufficient triple antibiotic or a gauze or use 163 00:08:12,800 --> 00:08:15,880 adaptic to avoid it. If the bandage sticks, soak the 164 00:08:15,880 --> 00:08:17,440 toe prior to removing the bandage. 165 00:08:17,440 --> 00:08:20,160 This is something we tell all of our patients and we get a number 166 00:08:20,160 --> 00:08:25,240 of phone calls every year about that we talked about before 167 00:08:25,480 --> 00:08:27,840 established patients. I'm going to talk a little bit 168 00:08:27,840 --> 00:08:31,080 about new patient office visits to keep it real simple for a new 169 00:08:31,080 --> 00:08:33,720 patient, if they come in, it's usually a quick visit where 170 00:08:33,720 --> 00:08:36,919 there's no real treatment done. So no X-rays done, no nothing. 171 00:08:36,919 --> 00:08:40,440 They just died some foot pain. I want to get looked at maybe an 172 00:08:40,440 --> 00:08:42,760 evaluation of an ingrown toenail without any treatment. 173 00:08:42,760 --> 00:08:44,520 Something like that would be a level 2. 174 00:08:44,880 --> 00:08:46,320 We don't do very many level twos. 175 00:08:46,320 --> 00:08:50,040 We're usually doing something Level 3 would be a more complex 176 00:08:50,040 --> 00:08:52,800 condition if we get imaging which is X-rays or an 177 00:08:52,800 --> 00:08:56,840 ultrasound, taking a nail sample, doing a plan for the 178 00:08:56,840 --> 00:09:00,320 future plantar fasciitis, initial visit without a 179 00:09:00,320 --> 00:09:03,120 prescription, OK. And then level 4 would be things 180 00:09:03,120 --> 00:09:06,560 that are more intense surgical discussions, just giving 181 00:09:06,560 --> 00:09:09,120 something that is an medication. We talked about these levels, 182 00:09:09,120 --> 00:09:12,320 these are billing levels and these are on on the billing tab 183 00:09:12,320 --> 00:09:14,480 that that we put in. But sometimes the front office 184 00:09:14,480 --> 00:09:17,160 staff, they need to know what level it is usual to will tell 185 00:09:17,160 --> 00:09:20,440 you, that's just kind of a reference for us. 186 00:09:20,600 --> 00:09:21,800 And there's this big billing sheet. 187 00:09:21,800 --> 00:09:24,360 I'm not going to go into it, but it talks about like you have to 188 00:09:24,640 --> 00:09:28,040 how many conditions you need and problems and what documents 189 00:09:28,040 --> 00:09:30,600 you're looking at. I'm going to talk a little bit 190 00:09:30,600 --> 00:09:33,720 about Anifix. So Anifix is different than 191 00:09:33,720 --> 00:09:35,920 carry flex. So carry Flex is used for ugly 192 00:09:35,920 --> 00:09:38,640 toenails to cover them up. It's the cosmetic procedure. 193 00:09:39,160 --> 00:09:41,760 If they have a damaged nail that's never going to get 194 00:09:41,760 --> 00:09:43,240 better. They'll come in once a year or 195 00:09:43,240 --> 00:09:44,920 twice a year and we'll do that for them. 196 00:09:46,040 --> 00:09:50,720 The onifix is used for ingrown toenails and it works better if 197 00:09:50,720 --> 00:09:55,200 the nail is flatter at the base. So with the base of the nail is 198 00:09:55,200 --> 00:09:57,760 this, this part's the base, so the base of the nail right here, 199 00:09:57,760 --> 00:10:01,720 if it's flatter here and then as it grows out, if it curves in, 200 00:10:01,960 --> 00:10:04,280 it works well. So let me give you an example. 201 00:10:04,280 --> 00:10:07,520 So if you look at this one, it looks like a a curly cue, right? 202 00:10:07,840 --> 00:10:11,480 And it's flatter at the base. So if it's flatter at the base 203 00:10:11,480 --> 00:10:15,400 and you apply the the the anifix, as it grows out it stays 204 00:10:15,400 --> 00:10:18,920 on the nail and as the nail grows it slowly pushes out and 205 00:10:18,920 --> 00:10:22,280 it'll bend, then that it'll it'll untwist the nail at the 206 00:10:22,280 --> 00:10:23,640 tip. That's what it does. 207 00:10:23,960 --> 00:10:30,640 So you can see these examples here curved in 124 weeks later. 208 00:10:30,920 --> 00:10:35,760 OK six months later and then you know and that's how it looks and 209 00:10:35,760 --> 00:10:38,840 as it's slowly grows out and then it grows out a lot of times 210 00:10:38,840 --> 00:10:42,440 we need to reapply these. I used to do it and then have 211 00:10:42,440 --> 00:10:43,600 people come back in three months. 212 00:10:43,600 --> 00:10:45,840 Now what I tend to do is I have them come back in when it falls 213 00:10:45,840 --> 00:10:47,520 off. So it might that might be longer 214 00:10:47,520 --> 00:10:51,240 period of time if there is enough space at the at the when 215 00:10:51,240 --> 00:10:54,200 they come back like let's say this, this has moved out here 216 00:10:54,360 --> 00:10:55,560 and there's enough room for another one. 217 00:10:55,560 --> 00:10:57,360 I sometimes put on two ANI fixes. 218 00:10:58,200 --> 00:10:59,800 It's applied to the base of the toenail. 219 00:11:00,000 --> 00:11:03,120 It trains the toenail to lift out the edges at the front. 220 00:11:03,960 --> 00:11:06,000 Repeat it every three to six months when it falls off. 221 00:11:06,360 --> 00:11:09,200 If it falls off under two months, I apply it without any 222 00:11:09,200 --> 00:11:11,240 cost. So if this is something that's 223 00:11:11,240 --> 00:11:13,240 not covered by insurance, I usually do it for free. 224 00:11:13,240 --> 00:11:18,320 If it falls off again because I like to guarantee it, There's no 225 00:11:18,320 --> 00:11:21,240 restrictions both with carry flex and ANI fix that we talked 226 00:11:21,240 --> 00:11:22,640 about before. There's really no restrictions. 227 00:11:22,640 --> 00:11:24,040 Patients as well. Can I do, you can do anything 228 00:11:24,040 --> 00:11:25,920 you want. There's a slight chance if 229 00:11:25,920 --> 00:11:29,440 you're a big runner, the carry flex and this the onifix could 230 00:11:29,440 --> 00:11:34,480 fall off. So if they if they if it falls 231 00:11:34,480 --> 00:11:36,600 off, I put it on again. I just charge an office visit or 232 00:11:36,600 --> 00:11:38,720 I let them know. If the office visit and if the 233 00:11:38,720 --> 00:11:41,640 nail is red infected and painful, we do an incision and 234 00:11:41,640 --> 00:11:42,840 drainage. That's where you numb it up and 235 00:11:42,840 --> 00:11:45,080 take out the edge with anaesthesia. 236 00:11:45,360 --> 00:11:48,920 If it's not successful then we'll either do a partial nail 237 00:11:48,920 --> 00:11:53,520 emulsion or we'll do a a matrixectomy. 238 00:11:55,160 --> 00:11:59,000 So orthotic dispensing. This is not an office visit 239 00:11:59,000 --> 00:12:01,120 normally. Sometimes what we do in the 240 00:12:01,200 --> 00:12:04,240 office is let's say I'm seeing a patient for heel pain and 241 00:12:04,240 --> 00:12:06,560 they're doing orthotics, I might do a three-week follow up for 242 00:12:06,560 --> 00:12:09,000 them. So I kind of do it in a way that 243 00:12:09,040 --> 00:12:11,000 it'll the orthotics I hope will be come in. 244 00:12:11,000 --> 00:12:14,440 That's kind of how I do it. Usually it's done at the front 245 00:12:14,440 --> 00:12:17,680 desk, but if you set your follow up for for three weeks, usually 246 00:12:17,680 --> 00:12:20,920 the orthotics are in and you can dispense them to the patient. 247 00:12:21,760 --> 00:12:24,840 They can make a dispensing visit if you want, but usually that 248 00:12:24,840 --> 00:12:27,480 builds an office visit. So some patients are are are 249 00:12:27,480 --> 00:12:30,920 concerned about the office visits, review shoe 250 00:12:30,920 --> 00:12:32,560 recommendations and make sure they're fitting well. 251 00:12:32,560 --> 00:12:34,960 I think that's key. Making sure they're fitting well 252 00:12:34,960 --> 00:12:37,960 in the shoe, making sure they're, they're, they know what 253 00:12:37,960 --> 00:12:40,320 shoes they can wear. You tend to want to do a shoe 254 00:12:40,320 --> 00:12:41,920 that has a sock liner that comes out. 255 00:12:41,920 --> 00:12:44,680 The sock liner isn't the thing that has the name of the shoe 256 00:12:44,680 --> 00:12:46,640 and that pull that out and they put the orthotic in. 257 00:12:47,480 --> 00:12:49,840 A couple of modifications that we can do in the office, we can 258 00:12:49,840 --> 00:12:51,440 heat it up and we can drop down the arch. 259 00:12:51,760 --> 00:12:53,200 So if the arch is too high, we can do that. 260 00:12:53,200 --> 00:12:57,080 But a lot of times we can send it back with both forward motion 261 00:12:57,080 --> 00:12:59,080 and Northwest, which are the two labs we use. 262 00:12:59,520 --> 00:13:00,760 Forward motion is a little bit easier. 263 00:13:00,760 --> 00:13:02,280 You don't have to send the device with it. 264 00:13:02,280 --> 00:13:07,200 You just kind of send back the orthotic and it works, works 265 00:13:07,200 --> 00:13:09,160 well and you say kind of what you want done, if you want it 266 00:13:09,240 --> 00:13:11,400 wider, if you want it longer or if you want the arch in a 267 00:13:11,400 --> 00:13:14,640 different place. It's always good to remind the 268 00:13:14,640 --> 00:13:17,640 patients, I know you give them the package, but it's good to 269 00:13:17,640 --> 00:13:20,960 let them know that there's a second pair for for $200 off. 270 00:13:21,440 --> 00:13:24,880 And the reason we do 2 pairs is because it just increases 271 00:13:24,880 --> 00:13:26,840 compliance of wearing the devices. 272 00:13:27,280 --> 00:13:28,960 So they're going to get better results because they're wearing 273 00:13:28,960 --> 00:13:31,240 them more, because most people have like a workout shoe and an 274 00:13:31,240 --> 00:13:33,960 everyday shoe, and so they can just leave them in those. 275 00:13:34,280 --> 00:13:36,880 I tend to get the first pair first to make sure they're 276 00:13:36,880 --> 00:13:38,080 comfortable, there's no adjustments. 277 00:13:38,080 --> 00:13:44,160 And then I'll do the second pair as needed, Pad, net or vascular 278 00:13:44,160 --> 00:13:46,280 testing. So this is a test that we do in 279 00:13:46,280 --> 00:13:48,920 the office. The staff does, why do we do 280 00:13:48,920 --> 00:13:51,160 this? Because our patients, most of 281 00:13:51,160 --> 00:13:54,440 them are elderly or have diabetes and those patients are 282 00:13:54,440 --> 00:13:57,720 at higher risk of developing PAD, which is peripheral 283 00:13:57,720 --> 00:14:02,280 arterial disease or clotting. The way I explained it to 284 00:14:02,280 --> 00:14:07,600 patients is that if you have let's say poor circulation to 285 00:14:07,600 --> 00:14:09,480 the legs, most people don't complain. 286 00:14:09,800 --> 00:14:12,840 Some might have what we call claudication, which is cramping 287 00:14:12,840 --> 00:14:15,080 in the legs, but for the most part our patients aren't 288 00:14:15,080 --> 00:14:16,560 complaining. But if you give, I'll give it an 289 00:14:16,560 --> 00:14:19,240 analogy. So if you had poor circulation 290 00:14:19,240 --> 00:14:22,640 to the to the carotid artery which is in your neck that could 291 00:14:22,640 --> 00:14:26,000 lead to a stroke. OK people many times it's under 292 00:14:26,000 --> 00:14:27,880 not diagnosed can lead to a stroke. 293 00:14:28,080 --> 00:14:30,520 If you have it in your heart it could cause a heart attack or 294 00:14:30,520 --> 00:14:32,360 circulation. It's all all the circulatory 295 00:14:32,360 --> 00:14:34,400 system. If you have it in your legs it's 296 00:14:34,400 --> 00:14:37,280 going to create a peripheral arterial disease which many 297 00:14:37,280 --> 00:14:40,680 times goes silent because the patients have neuropathy because 298 00:14:40,680 --> 00:14:42,240 they're just think their legs are tired. 299 00:14:42,720 --> 00:14:46,160 And that's why we do this test. It's it's an easy test. 300 00:14:46,160 --> 00:14:49,000 It's a lot easier than checking other things because you can put 301 00:14:49,000 --> 00:14:51,720 these blood pressure cuffs on their on the legs, three blood 302 00:14:51,720 --> 00:14:55,400 pressure cuffs and then one on the toe And it it we do this for 303 00:14:55,400 --> 00:14:58,800 patients that are high risk, OK. What was considered high risk 304 00:14:59,040 --> 00:15:02,440 diabetes is always high risk, OK, because diabetes has a high 305 00:15:02,680 --> 00:15:05,640 higher prevalence of clogging the artery. 306 00:15:05,640 --> 00:15:09,560 So diabetics over the age of 50 and then nine diabetics over the 307 00:15:09,560 --> 00:15:12,840 age of 70, OK. Also for patients that have 308 00:15:12,840 --> 00:15:16,640 ulcers to evaluate the healing potential, if it's really 309 00:15:16,640 --> 00:15:20,200 urgent, sometimes we send this out to the vascular lab only 310 00:15:20,200 --> 00:15:24,520 because we tend to schedule these, you know, on Fridays or 311 00:15:24,520 --> 00:15:26,360 other days when when staff is available. 312 00:15:26,360 --> 00:15:28,320 So we we don't do them every single day. 313 00:15:28,320 --> 00:15:31,400 We repeat them usually yearly because we want to see if 314 00:15:31,400 --> 00:15:35,400 there's any changes in the in the circulation and the results 315 00:15:35,400 --> 00:15:38,080 will come back as mild, moderate or severe. 316 00:15:38,800 --> 00:15:40,880 Most of them, ours come back mild and moderate. 317 00:15:40,880 --> 00:15:43,120 If it's mild to moderate, we usually evaluate it. 318 00:15:43,120 --> 00:15:45,200 We don't. Well, we just evaluate it again. 319 00:15:45,200 --> 00:15:48,640 We send the results to the doctor and then the following 320 00:15:48,640 --> 00:15:51,560 year we'll see if it changes. If if there's a drastic change 321 00:15:51,560 --> 00:15:53,960 or if they have more symptoms, then we will refer them to a 322 00:15:54,000 --> 00:15:56,400 circulation Dr. OR called a vascular surgeon. 323 00:15:57,280 --> 00:16:00,040 It usually takes 30 minutes to do this procedure by the staff. 324 00:16:00,040 --> 00:16:02,920 They have to remember to bring in shorts or or they're going to 325 00:16:02,920 --> 00:16:04,920 put on a Johnny OR or something else like that. 326 00:16:06,760 --> 00:16:10,040 OK we we talked a little bit about I I just kind of bunched 327 00:16:10,040 --> 00:16:13,840 all these together only because what I was using was the the the 328 00:16:14,040 --> 00:16:17,560 cash pay pricing kind of thing. But a paronychia is different 329 00:16:17,560 --> 00:16:20,080 than an Abscess which is different than assist I and D 330 00:16:20,080 --> 00:16:22,440 but I just want to explain they're all kind of infections. 331 00:16:22,520 --> 00:16:24,920 So a paronychia is an infection of an ingro and toenail. 332 00:16:25,200 --> 00:16:27,640 So an example of pus coming out the nail, this redness right 333 00:16:27,640 --> 00:16:30,000 here, you're going to either do the whole take the whole nail 334 00:16:30,000 --> 00:16:33,720 off or just take the edge of the nail and Abscess is is an 335 00:16:33,720 --> 00:16:36,920 infection usually in the in the skin. 336 00:16:37,040 --> 00:16:40,680 And and then you would have to numb it up and and and and and 337 00:16:40,680 --> 00:16:43,840 cut through it to do a call in an I and D And then there's also 338 00:16:43,840 --> 00:16:48,480 a cyst I and D, which if there's a cyst not so much a ganglion 339 00:16:48,480 --> 00:16:49,680 cyst. But if there's like another type 340 00:16:49,680 --> 00:16:53,280 of a cyst in there that you would cut it and you would drain 341 00:16:53,280 --> 00:16:56,760 the fluid. So that would be that you can 342 00:16:56,760 --> 00:16:59,640 even an aspiration as well. It's used for an infected 343 00:16:59,640 --> 00:17:02,360 ingrown toenail where you remove the painful edge or you remove 344 00:17:02,360 --> 00:17:05,440 the total total toenail. Used to drain out the prevalent 345 00:17:05,440 --> 00:17:09,920 Abscess or used to drain a ganglion cyst if it's not 346 00:17:09,920 --> 00:17:12,720 infected. We do not usually give 347 00:17:12,720 --> 00:17:14,720 antibiotics. This is a question that that 348 00:17:14,720 --> 00:17:19,760 differs us than a lot of the Eds or the urgent cares is they tend 349 00:17:19,760 --> 00:17:20,880 to give antibiotics for everything. 350 00:17:20,880 --> 00:17:24,640 Once you take out the nail and you and you have them soak it, 351 00:17:24,640 --> 00:17:26,720 you don't usually need an antibiotic. 352 00:17:26,720 --> 00:17:28,800 If there is a lot of redness you can do an antibiotic. 353 00:17:28,840 --> 00:17:32,080 But for a lot of our patients we we do not do antibiotics. 354 00:17:34,160 --> 00:17:39,040 Remi laser for pain management, we we we do a little bit of this 355 00:17:39,040 --> 00:17:40,440 but not too much with this laser. 356 00:17:40,440 --> 00:17:45,480 So this has a pain setting on it and what you do is you you you 357 00:17:45,480 --> 00:17:47,720 move it back and forth on the area of pain kind of in a 358 00:17:47,720 --> 00:17:50,400 swooping motion kind of all around it. 359 00:17:50,400 --> 00:17:54,000 Kind of like we do a shockwave, you perform it on the pain 360 00:17:54,000 --> 00:17:57,280 setting, it usually takes 5 to 10 minutes and you do 6 361 00:17:57,280 --> 00:18:00,840 treatments once a week or twice a week for three weeks. 362 00:18:01,200 --> 00:18:03,960 And this can be done by staff, can be done by the doctors, it 363 00:18:03,960 --> 00:18:06,200 can be done in conjunction. So sometimes we're doing it in 364 00:18:06,200 --> 00:18:09,960 conjunction with with like Shockwave, you put the pain 365 00:18:09,960 --> 00:18:12,800 setting on and you check every two minutes until the pain is 366 00:18:12,800 --> 00:18:14,880 reduced. So the the determination if it's 367 00:18:14,880 --> 00:18:19,520 working is if the if the pain when you push is working, 368 00:18:19,520 --> 00:18:22,520 there's there's no pain. Like I said, it can be done with 369 00:18:22,520 --> 00:18:24,840 shockwave. Prior to the shockwave and your 370 00:18:24,840 --> 00:18:27,560 treatment is complete when the pain has reduced. 371 00:18:27,880 --> 00:18:30,800 So what it does is it uses the laser light to heat up and it 372 00:18:30,800 --> 00:18:33,360 stimulates blood flow. All these treatments that we do 373 00:18:33,600 --> 00:18:35,920 kind of stimulate blood flow. This one stimulates shockwave, 374 00:18:35,920 --> 00:18:40,840 stimulates blood flow. Talk a little bit about routine 375 00:18:40,840 --> 00:18:42,400 care. I just want to explain a little 376 00:18:42,400 --> 00:18:45,680 bit about the difference. Routine care is a kind of a a 377 00:18:45,680 --> 00:18:50,560 difficult, challenging kind of animal in the office because 378 00:18:50,560 --> 00:18:52,960 some patients are covered, some are non covered. 379 00:18:52,960 --> 00:18:54,480 I'm going to explain the difference. 380 00:18:54,480 --> 00:18:58,760 Routine care just means diabetic or non diabetic foot care. 381 00:18:58,760 --> 00:19:00,840 That and that usually entails trimming of the nails or 382 00:19:00,840 --> 00:19:02,560 debriding. So the difference trimming is 383 00:19:02,560 --> 00:19:04,600 when it's a thin nail. A normal nail we call it 384 00:19:04,600 --> 00:19:07,200 trimming. Debriding is where we trim down 385 00:19:07,200 --> 00:19:09,240 or cut down the thick nails. That's debriding. 386 00:19:09,720 --> 00:19:14,360 And then we also trim or or debride calluses, OK. 387 00:19:14,600 --> 00:19:16,280 There's just technical terms that we use. 388 00:19:18,360 --> 00:19:20,800 We usually in some reason, sometimes it's covered with 389 00:19:20,800 --> 00:19:22,760 insurance. And why would insurance cover 390 00:19:22,760 --> 00:19:24,080 it? They're covering it for a 391 00:19:24,080 --> 00:19:26,240 patient that's considered high risk, OK. 392 00:19:26,440 --> 00:19:28,520 So someone that they could lead to an amputation. 393 00:19:28,520 --> 00:19:30,960 So not doing that care would lead to an amputation. 394 00:19:32,080 --> 00:19:34,840 Usually it's for thick fungal toenails that are derided, it's 395 00:19:34,840 --> 00:19:37,880 covered by insurance. Normal thickness nails usually 396 00:19:37,880 --> 00:19:40,280 are not unless they have what we call class findings. 397 00:19:40,600 --> 00:19:42,960 So class findings are something that we would document in the 398 00:19:42,960 --> 00:19:47,480 physical exam findings and usually indicate something like 399 00:19:47,480 --> 00:19:49,320 a peripheral vascular disease, PVD. 400 00:19:49,400 --> 00:19:53,880 So like non palpable pulses, diabetes with proliferative 401 00:19:53,880 --> 00:19:57,200 vascular disease, diabetes with neuropathy or lack of sensation. 402 00:19:57,200 --> 00:19:59,160 So we would check with that little Sims, Weinstein, that 403 00:19:59,160 --> 00:20:01,480 little, little piece of plastic we push on there. 404 00:20:01,560 --> 00:20:03,960 Foot and if they can't feel it, that kind of indicates 405 00:20:03,960 --> 00:20:06,920 neuropathy and then different circulation things like 406 00:20:06,920 --> 00:20:09,200 Raynaud's and and and different diseases. 407 00:20:09,560 --> 00:20:13,520 Regular callus trimming is usually not covered unless they 408 00:20:13,520 --> 00:20:15,560 have these class findings or they're high risk. 409 00:20:15,960 --> 00:20:18,960 So not not just everyone that wants their calluses trimmed can 410 00:20:18,960 --> 00:20:20,680 come into the office and have the calluses trimmed. 411 00:20:20,680 --> 00:20:22,120 They can do it, but they just have to pay. 412 00:20:22,480 --> 00:20:24,120 Now I want to explain a caveat here. 413 00:20:25,120 --> 00:20:28,080 There is something that is not it's it's kind of a callous, but 414 00:20:28,080 --> 00:20:32,440 it's called a porokeratoma. Poro means pore like a sweat 415 00:20:32,440 --> 00:20:34,400 gland. Keratoma is callous. 416 00:20:34,560 --> 00:20:37,280 So these things we see a lot of times in the office, they they 417 00:20:37,280 --> 00:20:39,560 get confused for warts. It's a callous with a really 418 00:20:39,560 --> 00:20:42,080 deep core in there. And then what we do is we trim 419 00:20:42,080 --> 00:20:45,920 off the upper callous, we cut out the center and then we put 420 00:20:45,920 --> 00:20:48,720 in one of those circular pads that we have the felt pads with 421 00:20:48,720 --> 00:20:51,840 a hole in it and then we put salicylic acid in the middle. 422 00:20:52,320 --> 00:20:54,800 When we do that, that's called lesion destruction. 423 00:20:54,880 --> 00:20:58,040 So it's it's we use lesion destruction codes similar to a a 424 00:20:58,040 --> 00:21:01,120 wart, but the lesion destruction code is for anything that we're 425 00:21:01,120 --> 00:21:04,520 destroying, usually do it once, one time if you're seeing 426 00:21:04,520 --> 00:21:08,200 someone back like every three months to do poro keratomas that 427 00:21:08,200 --> 00:21:10,040 might turn into routine care, right. 428 00:21:10,080 --> 00:21:13,240 Because usually when you're doing this it after a couple of 429 00:21:13,240 --> 00:21:15,320 sessions it it should resolve OK. 430 00:21:15,320 --> 00:21:18,240 So that that's a kind of a a high level understanding of of 431 00:21:18,240 --> 00:21:23,560 routine care. Let's talk about strapping of 432 00:21:23,720 --> 00:21:27,040 ankle, foot, hammer, toes and fractures. 433 00:21:27,200 --> 00:21:31,480 OK, Well, we don't do a lot of ankle strapping basically 434 00:21:31,480 --> 00:21:32,760 because of the time that it takes. 435 00:21:33,000 --> 00:21:36,320 Many times physical therapists will do ankle or this is called 436 00:21:36,320 --> 00:21:40,400 the Lodi strapping where you take tape and you tape it up the 437 00:21:40,400 --> 00:21:42,120 foot and this gives support to the arch. 438 00:21:42,400 --> 00:21:44,960 What are some ways that we kind of mimic this in the office? 439 00:21:44,960 --> 00:21:47,240 We do compression sleeves that kind of mimics it. 440 00:21:48,240 --> 00:21:52,720 We'll do an over the counter arch support or do an orthotic. 441 00:21:52,960 --> 00:21:55,520 So these all help patients that tend to have like plantar 442 00:21:55,520 --> 00:21:57,200 fasciitis and other types of pain. 443 00:21:57,400 --> 00:21:59,640 OK, but we don't do a lot of strapping in the office 444 00:22:00,320 --> 00:22:02,720 fracture. Someone has a toe fracture. 445 00:22:02,720 --> 00:22:04,840 We do do this. This is a buddy taping. 446 00:22:04,840 --> 00:22:08,000 So you take Coban 1 inch, Coban tape the two toes together. 447 00:22:08,000 --> 00:22:12,360 You tend to tape the bigger toe to the the, I'm sorry, the the 448 00:22:12,360 --> 00:22:14,360 fractured toe. You tape it to the to toe that's 449 00:22:14,400 --> 00:22:17,680 adjacent and bigger to it. Use one inch Coban and they just 450 00:22:17,680 --> 00:22:19,280 take it off from the shower and they put it on again. 451 00:22:19,280 --> 00:22:22,760 And you do that until they feel better along with the surgical 452 00:22:22,760 --> 00:22:26,680 shoe or walking boot. OK Then for hammer toes, there's 453 00:22:26,680 --> 00:22:29,080 different types of strapping. You can strap the toe down. 454 00:22:30,640 --> 00:22:33,560 That's for like a a hammer toe or what we call capsulitis or 455 00:22:33,560 --> 00:22:35,880 metatarsalgia that's in the in the front of the foot. 456 00:22:36,400 --> 00:22:39,600 You kind of pull it down and that's going to make it feel 457 00:22:39,600 --> 00:22:41,640 better temporarily. Another thing that you can use 458 00:22:41,640 --> 00:22:44,000 is something called the boudin splint, which is right here. 459 00:22:45,240 --> 00:22:46,960 Boudin splint kind of pulls it down to. 460 00:22:46,960 --> 00:22:48,480 These are called considered strapping. 461 00:22:48,480 --> 00:22:51,840 So you could say you strapped it with this and then you can 462 00:22:51,840 --> 00:22:54,320 build, build those things, OK With these types of of 463 00:22:54,320 --> 00:22:58,680 treatments, laser scar treatment, we don't do this a 464 00:22:58,680 --> 00:23:00,800 ton. But for some patients that have 465 00:23:00,800 --> 00:23:04,080 contracted scars or thick scars or elevated scars, here's an 466 00:23:04,080 --> 00:23:06,640 example. Before and after you can do 467 00:23:06,640 --> 00:23:08,280 this. I usually do four to six 468 00:23:08,520 --> 00:23:10,400 sessions. And in the in the medical record 469 00:23:10,400 --> 00:23:12,960 is the actual settings you put on the laser. 470 00:23:12,960 --> 00:23:16,400 I use the Qterra laser for this. It helps reduce stress and 471 00:23:16,400 --> 00:23:18,320 tension on the scar. So what I say is when you have a 472 00:23:18,320 --> 00:23:20,640 scar, everything is kind of confused in the in the in the 473 00:23:20,640 --> 00:23:22,640 tissues. And then as you heat it up, 474 00:23:22,640 --> 00:23:24,880 it'll all kind of flatten out and make it a little bit more 475 00:23:24,880 --> 00:23:27,440 normal, OK? And it can reduce discoloration. 476 00:23:28,080 --> 00:23:30,560 I use this with in conjunction with like taping the skin. 477 00:23:30,720 --> 00:23:32,560 Putting tape on the skin reduces stress. 478 00:23:32,800 --> 00:23:35,320 There's silicone tape that can be used as well and there's also 479 00:23:35,320 --> 00:23:36,960 cortisone and injections and other things. 480 00:23:39,120 --> 00:23:41,480 Nail debridement just explaining the difference. 481 00:23:41,640 --> 00:23:43,640 This is a debridement. It's considered if there's very 482 00:23:43,640 --> 00:23:45,840 thick nails. So if the nails over 3mm in 483 00:23:45,840 --> 00:23:48,600 thickness we consider that debriding of the nail. 484 00:23:49,320 --> 00:23:51,800 It's different than trimming. When we build it. 485 00:23:51,800 --> 00:23:54,440 We build it from 1:00 to 5:00 nails or 6 plus nails. 486 00:23:54,440 --> 00:23:57,760 I know it's funny but that's how we do it and it's covered 487 00:23:57,760 --> 00:24:01,320 usually every 61 days. If the nail is detached or the 488 00:24:01,440 --> 00:24:04,160 the nail bed is disappearing, what that means is let's say 489 00:24:04,160 --> 00:24:05,680 this nail. If you cut this all the way back 490 00:24:05,680 --> 00:24:08,320 and there's only this little bit right here that's left, then you 491 00:24:08,320 --> 00:24:11,240 could apply that carry flex to it to make it look good if they 492 00:24:11,240 --> 00:24:12,320 if they wanted to for the summer. 493 00:24:12,560 --> 00:24:16,080 OK, this just going back, this would not be a good candidate 494 00:24:16,760 --> 00:24:19,360 for laser because it's so thick, right? 495 00:24:19,360 --> 00:24:22,360 If you had a thinner nail, it would be This was a better 496 00:24:22,360 --> 00:24:24,080 candidate for the oral medication. 497 00:24:24,800 --> 00:24:28,080 OK, nail trimming. These are just normal nails, you 498 00:24:28,080 --> 00:24:30,400 just trim them. They're nails that are not 499 00:24:30,400 --> 00:24:32,760 thick. They tend not to be ingrown. 500 00:24:33,520 --> 00:24:36,080 If they're ingrown, then we would use an anaesthesia to numb 501 00:24:36,080 --> 00:24:38,720 it up when we numb it, when we numb it at the base of the nail 502 00:24:40,880 --> 00:24:43,960 ulcer debridement. I don't want to go everything 503 00:24:43,960 --> 00:24:45,720 into ulcers with you, but I just want to. 504 00:24:45,720 --> 00:24:47,520 These are some patients we typically see in the office, 505 00:24:47,520 --> 00:24:48,960 like an ulcer on the 5th Meta Head. 506 00:24:49,880 --> 00:24:53,480 Ulcers are graded. Most of the ulcers that we see 507 00:24:53,480 --> 00:24:56,320 in the office are grade one or grade 2. 508 00:24:56,760 --> 00:25:01,400 So a Grade 0 is nothing, OK? There's no ulcer, no symptoms. 509 00:25:02,720 --> 00:25:07,640 A Grade 1 ulcer is an ulcer. That's superficial, meaning it's 510 00:25:07,640 --> 00:25:09,360 just the top of the skin, kind of like a blister. 511 00:25:09,360 --> 00:25:13,120 This would be a Grade 1A, Grade 2 ulcer is going deeper. 512 00:25:13,120 --> 00:25:15,320 So it would go down to the tendon or ligament. 513 00:25:15,600 --> 00:25:18,360 And that, you know, you might think I'm not seeing the tendon 514 00:25:18,360 --> 00:25:20,280 ligament, not in this area, but if it's right out of toe, the 515 00:25:20,280 --> 00:25:24,240 tendon and ligament is really close By grade three, it goes 516 00:25:24,240 --> 00:25:26,280 down to the bone. So if it probes down to the bone 517 00:25:26,280 --> 00:25:29,560 or you divide the tissue down to the bone, that would be a Grade 518 00:25:29,560 --> 00:25:33,320 3 where you can see the bone or touch the bone, OK. 519 00:25:33,640 --> 00:25:36,160 And then grade 4 is where there's a lack of circulation, 520 00:25:36,160 --> 00:25:40,200 which is called gangrene. And then Grade 5 is really bad. 521 00:25:40,960 --> 00:25:43,480 We don't see that that much. There are different depths of 522 00:25:43,480 --> 00:25:48,480 ulcers. The the grade of an ulcer it is 523 00:25:48,480 --> 00:25:50,880 how deep it goes, like if it probes to bone then you would 524 00:25:50,880 --> 00:25:55,560 call that grade three OK Or in our notes it says it goes down 525 00:25:55,560 --> 00:25:57,000 to bone. It doesn't really say grades, it 526 00:25:57,000 --> 00:25:58,680 says it goes down to bone or things like that. 527 00:25:59,360 --> 00:26:02,840 Where you debride the depth of debridement is different. 528 00:26:02,840 --> 00:26:05,720 So you might not debride the might not take the bone out but 529 00:26:05,720 --> 00:26:08,800 you'll you'll take the tissue lower lower down in there. 530 00:26:08,800 --> 00:26:11,480 So it's different what it's superficial meaning when it's 531 00:26:11,480 --> 00:26:14,560 closer to the top of the skin kind of a this simple one like 532 00:26:14,560 --> 00:26:17,680 this we use a Mara gel, triple antibiotics or Betanine. 533 00:26:18,360 --> 00:26:21,080 We would use Betadine more if it's if it's if there's some 534 00:26:21,080 --> 00:26:24,120 dampness or maceration or like it looks like dish pan hands 535 00:26:24,120 --> 00:26:28,520 around it. If it's fibrotic or deeper we'll 536 00:26:28,520 --> 00:26:34,000 use like a collagen dressing or like a enzymatic debriser which 537 00:26:34,200 --> 00:26:35,840 there's one we call used called santal. 538 00:26:35,840 --> 00:26:38,880 At times if it's fibrotic and if there's drainage as well we use 539 00:26:38,880 --> 00:26:42,560 this this this collagen. We have the the collagen in our 540 00:26:42,560 --> 00:26:46,000 in our office and you can't just do that, you have to offload it. 541 00:26:46,000 --> 00:26:49,240 So we'll try to put these people in off loading walking boots 542 00:26:49,600 --> 00:26:51,960 that peg assist with those little pegs that you pull out or 543 00:26:51,960 --> 00:26:54,720 you do faltered foam. So PEG assist and felted foam 544 00:26:54,720 --> 00:26:56,640 are very similar. A felted foam is something that 545 00:26:56,640 --> 00:26:59,640 you do and that's why we like to do the PEG assist which makes a 546 00:26:59,640 --> 00:27:02,840 little bit easier for for taking those little plugs out. 547 00:27:03,040 --> 00:27:05,440 OK, You put that in a walking boot or a post op. 548 00:27:05,720 --> 00:27:09,760 And it's also good to evaluate circulation and verify that 549 00:27:09,760 --> 00:27:12,560 there's no bone infection with the X-rays. 550 00:27:13,160 --> 00:27:16,160 OK, Ultrasound guided cortisone injection. 551 00:27:17,280 --> 00:27:18,360 This is something we do quite a bit. 552 00:27:18,360 --> 00:27:21,320 Here's the ultrasound probe, Here's the injection. 553 00:27:21,480 --> 00:27:23,920 This is looking at the fascia like a normal fascia right here. 554 00:27:23,920 --> 00:27:27,880 This is a thin fascia and it's especially helpful for smaller 555 00:27:27,880 --> 00:27:31,000 joints like the first MPJ or mid foot joints, which are the 556 00:27:31,000 --> 00:27:32,200 joints in the middle of the foot. 557 00:27:32,720 --> 00:27:36,000 Because they're so small, you can inject one to two CC's in 558 00:27:36,000 --> 00:27:37,520 each area. It's helpful for plantar 559 00:27:37,520 --> 00:27:40,520 fasciitis, tendons, posterior tibial tendon, peroneal tendon, 560 00:27:41,320 --> 00:27:45,280 The other areas that we also could do cortisone, we could 561 00:27:45,280 --> 00:27:46,480 also do shockwave in these areas. 562 00:27:46,480 --> 00:27:49,840 So I tend to use ultrasound before shockwave and ultrasound 563 00:27:49,840 --> 00:27:51,800 helps find the area that's thickened. 564 00:27:52,160 --> 00:27:54,680 It's there's a dark area. It tends to be darker and 565 00:27:54,680 --> 00:27:58,480 thicker and you want to document this procedure that was done in 566 00:27:58,480 --> 00:28:00,800 in the notes and add it to the building and you save the 567 00:28:00,800 --> 00:28:05,120 ultrasound images prior to doing this. 568 00:28:05,600 --> 00:28:09,720 OK, this is a limited study of the ultrasound here. 569 00:28:10,080 --> 00:28:11,960 This is an example that I have from a presentation. 570 00:28:11,960 --> 00:28:13,840 You can see these examples right here. 571 00:28:14,080 --> 00:28:16,920 But I tend to show like the ultrasound what it looks like 572 00:28:16,920 --> 00:28:20,360 normal and thickened and I give some normal values for males and 573 00:28:20,360 --> 00:28:22,720 females. So I kind of explained this it's 574 00:28:22,720 --> 00:28:26,760 it's the most common study in the office, that most common 575 00:28:26,880 --> 00:28:29,720 study in the office that looks only at the affected anatomy. 576 00:28:30,320 --> 00:28:32,760 You look at it in two angles, which is longitudinal 577 00:28:32,760 --> 00:28:34,160 transverse. It just means you switch the 578 00:28:34,160 --> 00:28:37,240 probe in two different angles to look at the planet fascia 579 00:28:37,400 --> 00:28:39,120 Achilles tendon, posterativia tendon. 580 00:28:39,840 --> 00:28:41,800 Make sure the images are saved And once again if you want to 581 00:28:41,800 --> 00:28:44,360 look at some of my ultrasound images you can look here these 582 00:28:44,360 --> 00:28:46,280 those will be attached. This link will be attached 583 00:28:46,840 --> 00:28:48,920 ultrasound when building an injection. 584 00:28:49,680 --> 00:28:53,200 If we build a cortisone injection or aspiration or 585 00:28:53,200 --> 00:28:55,200 pulling out liquid and ultrasound, we use this 586 00:28:55,200 --> 00:28:57,560 category. It's less expensive than 587 00:28:57,560 --> 00:29:00,400 unlimited ultrasound. So limited ultrasound is where I 588 00:29:00,400 --> 00:29:01,800 actually look. And we're building an ultrasound 589 00:29:01,800 --> 00:29:04,120 which is usually the $100 or insurance covers it. 590 00:29:04,320 --> 00:29:09,120 If we're doing just a guided injection, we just charge $50 or 591 00:29:09,440 --> 00:29:10,800 we can bill it if insurance will bill it. 592 00:29:10,800 --> 00:29:13,280 It's it's just to visualize just that one area where I'm doing 593 00:29:13,280 --> 00:29:18,200 the injection unaboot. Unaboot is used to help if 594 00:29:18,200 --> 00:29:21,240 someone has venous stasis ulcers or wounds on the on the lower 595 00:29:21,240 --> 00:29:22,720 legs. Also, if they have a lot of 596 00:29:22,720 --> 00:29:25,080 swelling or if they have a sprain of their foot or sprain 597 00:29:25,080 --> 00:29:28,400 of the ankle, it's repeated weekly by the staff. 598 00:29:28,400 --> 00:29:31,000 If it's really bad for the ulcers, it's used to reduce 599 00:29:31,000 --> 00:29:34,440 ankle edema or swelling, tendonitis, foot instability. 600 00:29:35,200 --> 00:29:36,440 It can be used with a walking boot. 601 00:29:36,440 --> 00:29:39,080 You might have to take the top of The Walking boot off to fit 602 00:29:39,080 --> 00:29:41,000 it in there. You leave it on for three to 603 00:29:41,000 --> 00:29:43,720 five days and they can't shower or they would get a shower cover 604 00:29:44,080 --> 00:29:51,840 as well. Wart treatment or Veruca Veruca 605 00:29:51,840 --> 00:29:57,840 treatment. So faroukas there's one to five 606 00:29:57,920 --> 00:30:00,320 5 to 1415. Plus, this is the billing.