Treating the Whole Patient: A Personalized Approach to Lymphedema Care

0:10 Speaker 1 Hello there. I'm Brian. 0:11 Speaker 2 Growlo. 0:12 Speaker 1 Of Medi USA and I'm your host of the Magenta Lounge. 0:15 Speaker 2 Podcast and you are about to listen in on some great information. 0:19 Speaker 1 Brought to you by Medi USA. And I'm excited because I think we've got some really incredible guests coming to the table that we can. 0:28 Speaker 2 Get to know a. 0:29 Speaker 1 Little bit hopefully. 0:30 Speaker 2 Learn a whole lot more. 0:31 Speaker 1 From. 0:32 Speaker 2 But I need you to know a few. 0:33 Speaker 1 Things before we get started. 0:35 Speaker 2 And that is really that the information and the education that we bring to you. 0:39 Speaker 1 In this program. 0:41 Speaker 2 May not be the. 0:42 Speaker 1 Opinion of many USA's, or even mine for that matter. Nonetheless, I think you're. 0:46 Speaker 2 Going to have some great information and some great protocols and they are going to be an inspiring and if they do inspire you, bring them back to your care teams and your physicians. 0:57 Speaker 1 And decide that collectively. 0:59 Speaker 2 No one is. 1:00 Speaker 1 Here to tell you to override a physician's order or a whole team's assessment. 1:04 Speaker 2 Right, We always want to make sure when we hear new information, we're doing our own. 1:09 Speaker 1 Intel we're. 1:09 Speaker 2 Doing our own research. 1:11 Speaker 1 And we're bringing it back to a team of people that are in agreement with that. So I'm excited to get started. Again, Thank you so much for being here and I look forward to bringing you all these programs. Hello everyone, and welcome to the Magenta Lounge. 1:28 I am your host and friend, Brian Garolo, and I'm the director of Clinical Education here at Medi USA. My goal is simple. I literally just want to pass along good information that you can utilize and walk away with. 1:43 It's going to help you treat your patients better and set them up for lifelong success. There's a lot said in in doing that. Easier said than done, I should say. And my journey in lymphedema started years ago in 2003. 1:59 And the answer to that question I've been trying to answer for many, many years. How can I set patients up with the best long term situation? And also how can I treat patients better? What are the updated protocols? What are the best approaches? 2:16 All these questions are out there and I don't have all those answers, but through the years I have met tremendous people and I want to bring those people here on this program so that you can learn from them as well. There's so much to learn from, from so many different people, and they all have their passion and their expertise, and that's what it's all about. 2:37 And that's why we're here today. So I'm excited to introduce you to my guest today, whose name is Denise Kaminsky. Denise has an approach to lymphedema that I find to be very unique and very necessary. 2:55 One thing about Denise is that she has not forgotten her roots as a therapist. First, she's a yes, certified lymphedema therapist and Lana certified. She's wound care certified. She does vestibular rehab and she has her own practice. 3:10 She does so much on her own and she does all of it excellent. But and talking to her in the time that I've got to spend with her, I've just realized, wow, these are some really good insights that I think a lot of us could learn. So with me today is Denise. 3:25 Denise, welcome to the Magenta Labs. Thank you so much for being here and making the time for us. 3:30 Speaker 3 Thank you, Brian. I'm very happy to be here. And we get to talk about lymphedema. I can do that all day. 3:35 Speaker 1 Yeah, all day. I, I, I say the same thing. Yes, and I say that I think people think I'm joking, but actually kind of what we do, we've like thrown our energy and life. Yes. So yeah, I literally could talk about it all day, but don't worry, we will not do that. 3:51 We'll condense it down. So Denise, like I ask everyone there, I ask everyone their story because I feel like ending up in lymphedema is a one off, even though there's more of us out there and you've made more of them. One thing I forgot to mention is that you're an instructor for the Norton School of Therapy. 4:09 We'll get into all that stuff, but goodness, finding the niche of lymphedema in itself. Like tell us your story, how you got here. I'll dive in. 4:18 Speaker 3 Yes, it was like you said many moons ago. But I do remember the patient distinctly. I was doing mobile care. I was going into patients homes. One patient particular, I went in, she lived alone. 4:33 She was getting wound care from nursing and I went to do something with her transfer. Or can I just remember both of her arms had gauze wrapped around it but just this clear fluid just started leaking out and I thought OK whatever the nurse did wasn't working. 4:53 Several visits later, it was the same thing. It was just bandaged but soaking through her clothes. And this was probably mid 2000s, 2007, like we're in the 21st century. We have to have a better treatment for this. 5:09 So I started seeking out, you know, what is it fluid? You know, what is the swelling? And it led me eventually to 2009 when I became certified in lymphedema therapy. And I've been treating patients with lymphedema ever since. 5:25 Speaker 1 That's so awesome, and I love that you It all started with a need you treating a patient who had something you didn't quite know how to treat and you didn't just pass it off to somebody else. You said I need to figure this out, and that sparked a whole bunch of other things to get you to where you are now. 5:45 Yes. Also you mentioned the wound, and I have that. I also have that same story of like, OK, three months into being certified, I have this gigantic venous leg ulcer on the table. No idea what a venous leg ulcer is, by the way. I just know that it's a wound and there's hyperkeratosis all around it. 6:03 Again, I didn't know what that was either. And I'm just like, Oh my gosh, what do I do? Fortunately, I had a good mentor in those days and but I, I know that for me, I'd see kind of thing of like, I have a wound. 6:20 I could call someone else and refer or I can figure this out, right? And I love the figuring out. 6:25 Speaker 3 Part and that's the the investigative that was the detective work and but this person was already getting people in, so it wasn't even trying to pass off. They were already being passed off and and you're like, yes, the the buck stops here. We someone has to do something. 6:41 Speaker 1 They're we could do better. 6:43 Speaker 3 Yes. 6:44 Speaker 1 And I can figure that out. 6:46 Speaker 3 Yeah, for sure. I. 6:47 Speaker 1 Love that. That's really cool. So tell us a little bit about your lymphedema career. OK, So you have your own practice and I know you started that brick and mortar recently and tell us a little bit about that, but also want to know about your journey and being an instructor of lymphedema. 7:09 So for those of you out there, if you if you are Norton trained, there's a good chance Denise here has been your instructor. So hopefully for those of you that have been trained through Denise already know what a wonderful instructor and both the knowledge he is, but give us a little background on that. 7:25 Speaker 3 So treating lymphedema for many years, seeing wounds, That's why I also got my wound certification. Not something I thought I'd go into, but something you just stumble on and you have to do it, which I love now. 7:43 But I was doing mobile therapy for a very long time and I wasn't able to see more people. So I couldn't help more people. I can only see so many. The drive was starting to get longer. I couldn't add any more people on to the day. 8:00 So after more than a decade of doing mobile care, I decided just to take the leap and do the brick and mortar which we've had open now and I love. I mean, I see so many more people. I can do many more things. 8:16 And it's not about the the equipment that I can put in the clinic, but the time spent with them. But also, besides treating patients, I do workshops for the community. So one Saturday a month I will have a lipedema workshop. So it's free to the community and it's all about education because that was one of the things I loved about treating people with lymphedema is educating them, educating their caregivers. 8:42 Most of them never even heard of lymphedema, even from their doctors. It was something's wrong with your arms, something's wrong with your leg, go get treatment. So just educating them about it and now educating the community, which I absolutely love. 8:58 Again, a free event. I have a women's group, support group. So it's for women with breast cancer living with lymphedema. They call themselves the Pink Coconuts because we're in Florida, so we have a logo and everything, but it's just to bring them together to let them know they're not alone. 9:17 Breast cancer is one thing, but then lymphedema on top of that. So it's that that sense of community, that sense of, again, not being alone has helped so many of the women, but education. So I've never in a million years would have thought I'd get up in front of a classroom and and speak, but I actually so enjoy it. 9:40 And since 2018, I've been instructor for Norton for the CLT certification and I, I am so enjoy it, so interacting with so many different disciplines all over the country and it just definitely has made me a better clinician, being able to teach them the foundations and just reinforce the foundations for myself. 10:02 Speaker 1 Very cool. I think it's it's an incredible background training people to become certified lymphedema therapist. And I think that kind of leads me into my next question for you is I know you have started your own education platform. 10:18 I'll let you talk about that, what it's called. But as an instructor of or, or creating certified therapists, it sounds like now you are teaching advanced courses so that these now certified people can get to the next level, correct? 10:36 So tell us more about that. 10:38 Speaker 3 So I rolled it out this year. Pathways. Education programs, my first course that I'm offering, it's a three day 24 hours for advanced advancement in being ACLT. 10:53 The need was after I would see the students for the CLT course, they would contact me three months later, six months later, OK, what do I do with this, this person? What do I do in this situation? And it's not the same questions from all the students, but it's questions. 11:12 And either they don't have the mentor, they don't have the support in their facility, or they just run into complicated cases, which we all do because it's people we deal with. 11:27 So I definitely found the need to go outside the textbook, go outside the, you know, formal learning. I try in the courses to bring up my own case studies just to show them real people what really happens. But yeah, you run into so many comorbidities or something else that's going on. 11:46 So we need to address that. It's not just lymphedema. Treat it, be done. But I've also found that when I started assisting and then instructing how much over the years, I kind of waxed and weaned from the the the foundation. 12:04 And it happens to all of us as we're people. So I think therapists need kind of that reboot that really, what are you doing with your bandages now? What did you start to take away or what have you changed just because your admin told you to? 12:20 So having to kind of dust off the book, go back to basics, but then learning how to treat, you know, changes in cancer treatment has changed how the book has taught us. And we may not have all the updated information, but I see I don't see maybe limb lymphedema. 12:42 I do see now trunk more than we used to, you know, decades ago. So seeing these changes, because of how medicine changes, we have to stay updated and we need support. Most of the clinicians are out in the wild by themselves. 13:02 So, you know, the webinars are great. I'm not taking anything away from the online learning, but my, I see it as these therapists need someone next to them. Here's how your hand should look. Here's how you should stand even. I mean, that makes a big difference in how you treat someone. 13:17 Speaker 1 Amazing. Well, that's incredible. And with that, I have a lot of follow up questions for you because I I think it's perfect for what's needed out there. And with your experience and your instructing experience, you are the perfect person for it. 13:34 So let's talk about that before we do short little break from our sponsor who happens to be Mehdi. We'll be right back. 13:46 Speaker 3 Medi compression garments are a big part of my life. I've been wearing them since I was a little girl. They really help me live life in the sense that they control my swelling, keep it under control. They're very comfortable to wear. I I can't live without them to be honest. And I really do love the fact that they come in so many different colors and patterns. 14:06 The new Medi Compression glove that I'm wearing is seamless now, and I love the material on it. It's very flexible. It makes it easier for me to move my fingers, and that really helps me do daily activities easier. It's like a second skin. 14:25 Speaker 1 All right, everyone, welcome back to the Magenta Lounge with our special guest, Denise Kaminsky. Denise, I want to jump into your approach to lymphedema therapy because like I said earlier, I think it's the unique approach You're integrating not just lymphedema therapy, but you're looking at the whole person and very holistic approach, I would say. 14:47 So let's talk a little bit about how you jump into this with a patient. 14:56 Speaker 3 As soon as they walk through the doors, it's you're analyzing. As a therapist, you're constantly assessing, but it's simple, it's an individual approach. Even if I've seen the same diagnose 10 patients before, it's you have to look at the person, you need to know what their issue is, what their problem is, what they came to you for, how you can help them and then work on the goals together. 15:26 And again, it's not just swelling or the wound. There's other issues going on. Again, they're people. So, you know, they have the mobility, maybe they're socially isolated, you know, maybe they're falling. There is something else as therapist that we can and should help them with. 15:46 And sometimes that's priority. I've had people with their fall risk was too great. I couldn't bandage their leg. And that was OK because I worked on the fall, the fall risk. I worked on their balance, their strengthening. I think we as therapist, and maybe it's from administration, I don't know, but we want to jump in and just do our MLD, do our bandaging and then move them on. 16:11 But you can't because they have so many other problems. Maybe that's what got them there into this situation. So every person should be treated as such as as a person. And we know you can include CDT as part of it and that's a big part, but that's not the only part. 16:32 I typically will see someone, I do the evaluation, It's all education. I do my measurements, my assessments, but I'm, I find out, OK, what are we trying to get? We trying to reduce, we trying to get the wound healed or we just sticking to maintenance. 16:49 We, we want to just preserve the limb and not let it progress. So it depends on what our objectives are. If we're going to reduce, then we need to just step into CDT. If they're ready for it and I talked to them before they come for a visit, before I even touch them, is Are you ready to commit? 17:08 If you're not ready to commit, we need to find a time. You are because I can't be the only one giving in this situation. So I, I we talk about, you know, maybe someone is going on a cruise in a month and they can't commit until after the cruise. 17:23 OK, come back. I've had some people I need, I need to find transportation. Fine, come back when you have transportation. We try to help them as much as we can. I have an awesome person in the office. 17:37 Speaker 1 Oh yeah, Tell us about. 17:38 Speaker 3 That person, that person is Jason. He is the business manager, so he's also my husband. So I have to give him props. But no. But if you know, we, we do help them as much as we can with what we're given and and our limited resources. 17:55 But yeah, they come in, they have to know the schedule. You know, I've had people say, well, I can't come that often to see you. OK, well, this isn't for you. You know when you can commit. Let's do this. But I'm not going to water down a treatment just because I got to fit around their soap opera times or whatever. 18:14 Whatever. Yeah, they want. They want to make an excuse. This is health. This is for their health. This is long term. This isn't going away. So when they're ready, you know, I'm here for them. And I tell them that you can come back anytime if they're ready to start. 18:30 We get them on the schedule and we just, you know, do the whole CDT. Yeah. 18:36 Speaker 1 I think it's pretty obvious that you're a lymphedema therapist. You're seeing lymphedema patients. Obviously the goal is to reduce, but like there's such a bigger picture there that you're looking at. Obviously you mentioned the fall risk, but whatever's going on in your life, you're looking at them and they walk to the door. 18:55 So how much what are your goals look like? Like what is your assessment look like? Are you writing goals that say we're going to reduce by this many centimeters here? We're going to, we're going to do MLD and try to, I don't know, fit into a shoe better. 19:15 Like what? Like what are the actual goals? I think people want to know how to write a proper assessment. The reason I bring this up is because we live in an LTA world now and documentation has always been important. We've always tried to be that into people. 19:31 But now it's like, if you want that garment right, you have to document why it has to have a real purpose, right? So what is your? What are your goals look like? 19:41 Speaker 3 So that is part of the course. I did go over documentation, assessments, what assessments you can do for certain areas. But yes the goal has to it. You just can't say reduce because insurances want to know why or the payer wants to know why. 19:57 So reduction is to prevent a fall risk so their limbs are not heavy. Their reduction is for the arm to fit into regular clothing because most of the women will say I have to buy a size up just to fit my arm into it so. 20:12 It can be so they can self feed themselves. The head and neck is is more specific. Yeah, that is something I do treat, but not as often. 20:24 Speaker 1 You mentioned trunk too, I wouldn't have AI would. How do you document to that? 20:29 Speaker 3 So to measurement wise, assessment wise, you just have to find points on the body to to make measurements. But again, fitting in clothing so they have the mobility to do movements to do to self transfer. So if you can't move your trunk because it's swollen, you can't get yourself out of bed yourself. 20:51 You can't put shirts on and things like that. So it has to relate to function because, yeah, we're drilled into our heads as therapist and the wound, but the wound, you know, why does the wound need to be healed? To prevent infection, but also so they can go out in public to go to the grocery store or so it should all be tied. 21:13 Skin care is always a goal of mine. If I'm doing edema reduction, edema reduction. But why? So they don't fall when you know, they can put their shoe on. I do, I'm trying to think what other goals that you know, I assessment goal. 21:29 So if I do an assessment, they have to be able to, if it's a the time get up and go, they can have better mobility to safely transfer. So I don't just do edema reduction. It is definitely more encompasses the whole of the person. They can do their own skin care maintenance. 21:46 They can put, they can identify what maintenance for a short term goal and they can actually perform the maintenance. So I don't cut someone off, get their garment and discharge. They have to have their garment, I need to see them back. They need to show me they can wear it, it fits, they like it. 22:05 I typically will see someone through the intensive phase, but as an outpatient clinic, I see them 90 days. I will typically see them for the whole time. I titrate the visits down so I don't see them five times a week. That's only initially. We go down to three times. 22:20 We transition to maintenance and then once they're in maintenance, they can come twice a week. Usually I'm working on other things, though. I start working on their balance. I start working on their strength. 22:31 Speaker 1 So your typical protocol for standard lymphedema patient is start off at five times a week. 22:37 Speaker 3 Yes, my and again, I say this during the evaluation with my patients because yes, they can stop at that. You want me to come how often when I put the bandage on the limb for reduction, the limb will reduce, but the bandage does not reduce that much. 22:54 And so if I bandage someone Monday and don't seem until Friday, their limb will reduce, but by Friday it's going to swell back into the bandage. You have no gains. So when you hear people, oh, I've been six months at a clinic with bandaging on, you probably have and you haven't probably reduced much. 23:13 You have to, you have to do the five times you have to get that. The biggest bang for your buck is five times a week. Yes, the weekend. I hear that a lot. Yes, wear it. I don't work weekends and you have to wear it until Monday. Other things can come into play for the weekend, but you will see that biggest reduction the first week. 23:33 I measure every week. If I don't see a reduction, I stop what I'm doing and I have to change. I tell someone I'm not going to just treat you to treat you. If you're not reducing, we're not improving. We have to stop and see what else is going on. So the first two weeks are typically 5 days. 23:48 At that point, usually the second week, they don't reduce as much. Or if they're willing and they're still reducing, we do a third week. And then as soon as we have that slow down, that plateauing of measurements, then we can go down to maintenance, we switch to it. But I still have to bandage, which means I order, we order, we come to some agreement on what we're going to order at the end of the intensive, I'll measure for custom, for Velcro, for whatever they need. 24:14 And then I still bandage them to maintain that reduction. Most of the time they don't have anything to go into. So I still have to bandage them just to prevent that edema from coming back. And then once they get all their supplies again, we can go down it twice a week. 24:30 But I got to make sure they're wearing it like they say they're supposed to, that they can get it on and that it's working because they can wear it. And maybe the first week it doesn't work. Excuse me. So then I know, OK, we need to do something different. So it has to be a maintenance that works as well. 24:47 Speaker 1 And within that scope of practice, you're addressing lymphedema, but you could also be doing balance training for regular OT. 24:58 Speaker 3 Correct. 24:59 Speaker 1 Implemented into that treatment. So it is, it is fully comprehensive of yes, you're OT, yes you're ACLT, but you're merging all of it together into one approach. 25:12 Speaker 3 Right and so depending if if you know the CDT would become primary, we do the five times a week. But once we start going down less and less, switch to maintenance, then you start to work on, you know, how is their strength? How was there? Are they reaching, you know, are they able to functionally move and in transition? 25:31 So yeah, we work on, you know, just stretching just to get that sock on, to bend over, make sure they're cleaning between their toes, make sure they can lift their arm over their head to get the the microwave. So yeah, we we start working on more traditional therapy. 25:47 Speaker 1 Nice, well, that's amazing. I think that's so important for everyone to know just because I, I think we learn to be CLTS and we we go after that and there's just so much going on with an individual. 26:03 You do have to just take every patient and customize their treatment. So that makes total sense. Very good. All right. 26:13 Speaker 2 Medi USA welcomes some amazing new additions to our custom circular profile line with enhancements like the Easy Grip panel on the sole of the foot for safe mobility during the night hours, Slim Channel Foam in addition to our Classic Channel Foam for a slimmer fit. 26:30 Speaker 1 The option for soft. 26:31 Speaker 2 Foam as well as classic foam to address variations in fibrosis and the ability to integrate our easy band and easy band lift but endless adjustability. Our nighttime compression is more comprehensive than ever. 26:53 Go to mediusa.com for more details. 26:57 Speaker 1 All right, Denise, I want to switch gears just a little bit. Of course I you know, I'm going to talk about compression. 27:04 Speaker 2 How could I not? 27:04 Speaker 1 Right, But you also heard me say, and I say it all the time, like the maintenance phase of treatment is so important because it's, it's lifelong. And I feel like experts like yourself and, and me like, and lots of therapists out there. 27:21 We, we provide amazing therapy. We do a great job limb reduces, but then we have to shift that to the patient. And that is that is a task within itself and really difficult. I mean, so many, there's a lot of different choices out there in compression, but there's also a lot of different, different aspects about the patient that might hinder them from going into the compression that you might want them in. 27:48 There's just so many aspects about it and I want to talk about it. I want to talk about how you look at setting someone up for their maintenance phase and choices you might offer somebody or how you just decide all that. It's a big, it's a big question. 28:02 Speaker 3 It is. It is. But I I take that from the very beginning, the first visit that I see someone. Again, my evaluation is mostly education, but that's exactly what I go into. I start talking to them. The reduction is the easy part. 28:18 The maintenance is what we need to start talking about. I tell them there are different options. We need to just not decide right now, but we need to start thinking about what we are going to transition into. So we don't have to make the the decision on which color and which, you know, cut and which length. 28:36 We just need to know what do we think we can do? 28:39 Speaker 1 So you're from the start, preparing them for what they're going to need in the future. You're not just waiting until now, you're going to go into garments. 28:47 Speaker 3 No, because the education, they need to know what they're getting into. If they come and they think, oh, I'll just get my massage and bandage and be done in a week. No, again, this is lifelong and I'm here to help them. We can make that decision together. 29:05 It is ultimately their decision there and their families or caregivers. But let's start thinking about it so this can be an easier transition because this will happen quickly once we reduce. I need to get measurements, I need to get the order out, and then it needs to come in. 29:20 They need to start wearing it. So we have to look at a lot of different things. Ideally, I think for most people with swelling flatten it is pretty much the gold standard. But you have to take into consideration what they can do, their lifestyle. 29:36 So if they can't pull on a thigh high, flatten it because they're 80 years old with arthritis, we need to think something else. So there's great products out there outside of flatten it. We can do Circade, we can do Velcro again, we can do combinations of it, but it just depends on their ability and really, in the end, what are they going to do. 30:01 Speaker 1 Right, right. You brought flat knit, which which is awesome. I love flat knit. It's our go to admit it. We talk, we do a lot of talking about our flat knits and we talk about it in terms of containment, But I think there's still a lot of people that are maybe utilizing circular knit. 30:21 Any comments on that? 30:24 Speaker 3 Yes, circular knit is really not meant for people with swelling, so there's usually the two most common complaints when someone oh, I bought this online. I bought this at the store. I have pain at the ankle, the instep because it's digging in. 30:41 I have pain at the top because it's causing this this tightening, this tourniquet. Those are common, I think across the board. They don't fit right. They don't contain them. They wear them. They're like at the end of the day, my foot, my ankle are still swollen because the containment's not right. 30:58 So circular is is really meant for legs like yours or mine. The flat knit is for someone with swelling. Not only is it custom made, but it prevents the digging in, it prevents the tourniquet and in the containment is a such a big deal. 31:14 And I show my people that are in my clinic, I have the two different kinds. I show them what the circular feels like, looks like. I have them touch it with the flat knit looks like. So the containment on a flat knit. I explained it to my patients that if you have a pitcher of water and you pour that pitcher of water into a plastic bag, that bag is going to expand with the water. 31:36 It won't leak, but it will expand. You can take that same picture the same amount and pour into a glass cup and that wall doesn't move. That containment is is going to hold and that's the flatten it. The flatten it is the glass. It's it's going to keep that swelling from happening after 12 hours of standing on your feet. 31:56 Speaker 1 That's a incredible visual and so accurate. Gosh, that's a mic drop right there because it's like what we spend so much energy teaching people at Mehdi, and I love to get that word out there. It's nice to hear it from you because it's just singing our song, you know, the amount of energy we put into that we, we know containment is an ingredient that's been missing from compression for a long time and we are talking a lot about it, but we still see a lot of people choosing, circulating it. 32:30 So I think we've got to, we've got to tip that. 32:32 Speaker 3 And it's the education. And again, it's big for me, I think if if you can educate them, tell them why that helps them make better decisions. Because if you just tell someone to do something, they end up usually not doing it. 32:47 Speaker 1 I was never that way. 32:49 Speaker 3 So if you give them, you know, you give them the information to know the why it's they're more likely to follow through. 32:58 Speaker 1 Why? Absolutely. That's where the education to me is everything. You can educate how and what, but if you educate to the why, you're getting at a different outcome. 33:09 Speaker 3 And you need to bring it to their level, whatever their level is. If I I've treated surgeons, I've treated someone that's never had a high school education. So you have to make sure they understand. So same with teaching, you know, other therapists CLT. 33:26 It's if I can't make them understand I didn't do my job and just me saying words is so different than having you actually understand what what words are coming out of my mouth. 33:40 Speaker 1 Yeah. I want to get into a little bit more detail on specifics of product choice at Medi. We have different flat Nets. We have different levels of containment and you mentioned Velcro as well and circuit and I'd love to know where all that falls in levels of containment or how you utilize it. 34:04 Speaker 3 For the flat knit, depending on really their mobility, how active are they? Are they sitting all day at a desk? Are they able to pull up the flat knit? If they cannot physically put a flat knit on, we definitely go to the circuit, the Velcro. 34:22 But again, I don't just give them a Velcro the circuit and say here you go, here's your, here's your maintenance. They need to come back. I need to make sure they're pulling the straps correctly. They have the sequence down. So again, you can't just discharge someone with a garment and say that's it, you, you succeeded, you, you graduated, you're done. 34:43 They need to come back because over time they start to lose how to put it on right. Oh, I forgot the liner. I just put it on against my skin. So there's so many factors to continually look at. So if flat knits are hard, which they can be hard to put on if they don't have the mobility, they have a lot of back pain, they're elderly that you know, they can't bend over. 35:05 Velcro is a great alternative that so surrogates are awesome for any of the limb, arm, leg, but they definitely need to know they can put it on, right. But it's also used for, I found with my patients that are going through active chemo, Velcro is a great alternative because with their chemo infusions, they're getting a lot of fluid pumped into them and they need that adjustability. 35:31 They need containment, but it hurts because they're getting all of this fluid which I can't control. So I have to allow a little bit of give. Velcro has been, the circades have been a great alternative for my patients going through active chemo. 35:48 So you can use it for not just your elderly. There's so many other things. It's great over wounds. Circade is a great product over wounds. And then you can use that for nighttime time or for their maintenance in that aspect. So you, you do have to, you can do a combination people can get flatten it and circuit. 36:08 So don't be afraid to use both to have both. 36:13 Speaker 1 Yeah, adjustability to me is a big deal. But when you're dealing with fluctuations, and I always have kind of taught that somebody can determine how swelling is going to respond based on what the bandaging is, right. 36:33 If they have a fast reduction, if they have a quick refill, you're assessing how bandaging goes, You're assessing how the decongestive phase goes. Depending on what your tool is for decongestion, you can determine so much on that to determine what your maintenance phase is going to be and what that needs to look like and how intense it has to be. 36:52 Speaker 3 I even do some trials, maybe on one of the last weekends they'll take it off and see how they refill at night. Even so, some people may not need a night time garment. Some people do. So we can do trial and errors. I know I can fix their swelling because they're coming back to me the next week. 37:10 So if we do a trial and error and it doesn't work out, they're back to see me. I can still take care of everything. 37:16 Speaker 1 Nice. Well, I think we have learned quite a bit from you and I really appreciate you being here and offering your knowledge and your past, what you've learned through it. Just like myself, your approach to therapy and utilizing all of your OT and lymphedema, We're looking at the patient from a whole perspective. 37:42 I think it's, I think it's something we all need to know and remember and consider when we're approaching these patients. So what I want to do in, in closing is just briefly talk about your education platform that you're working on. Because I know you have a course, you're putting it out there. 38:00 And I want people to know where they can find you to get those skills that they're that they want to advance to. I mean, you, you, you, you're working with new certified lymphedema therapist all the time. And like we said earlier, like you want to help people advance. 38:15 So tell us about what you've got going on, where you're holding classes and all all that good stuff. 38:21 Speaker 3 So it's you can visit the website pathways411.com. I do offer it's a three day course, 24 hour contact hours. It's in my clinic outside of Orlando, FL. If you do not, that'll be rough. 38:37 Yeah. Yeah. If you do not want to travel to Orlando to see the parks or the beaches, I do want to bring this to the community. So I, I'm offering hosting opportunities at your facility, at the universities. I want to bring this course to you. 38:55 So everything with it, it's talks about manual techniques. It goes over advanced manual lymphatic drainage. It goes over bandaging, making sure you can put a bandage on I'm. 39:07 Speaker 1 Nervous. If I come to your class, what am I going to expect? Are you going to slap the? 39:12 Speaker 3 Wrist I won't be judgy, but I'm going to make sure you do it right. When you leave, you will be confident in how to put on a bandage. 39:19 Speaker 1 I will sign up. 39:21 Speaker 3 We go over documentation, we go over making sure you what assessments need to be done, how you should word your goals. Everything needs to definitely line up with LTA. How do you do that? The billing codes, the CPT codes. So it's it encompasses the whole treatment of a person that has lymphedema. 39:41 Speaker 1 Nice. Well, awesome. And it sounds like a perfect opportunity for those people that are out there that maybe don't have the opportunity of mentorship or are just new at this, they're newly certified. Whatever the case may be, I'm going to be there. 39:56 And I've been doing this, like I said, for a long time. But I guarantee you I will pick something up from you that I didn't know before. I'll be, I'll be a little bit on edge though. I'm just kidding. I'm going. 40:07 Speaker 3 To make sure to call you out. No sitting in the back. 40:12 Speaker 1 Well, thanks for being here, Denise. So much appreciated and thanks for all that you do. And thanks everyone for listening in today. 40:20 Speaker 3 Thank you.