I have MG that decided to bring cancer along for the party. There are very limited videos that talk about MG from a patient point of view. Anytime I have been in the hospital, I have told the doctors and nurses that if anyone has questions about MG to ask me. That’s the only way for people to learn and I’m more than happy to help in anyway I can. Thank you again for the video on MG!
Hello, I have been suffering from severe sinusitis for exactly 30 years. I am Brazilian, I am 45 years old and today they are treating me at the HC Hospital das Clínicas in São Paulo. I had a relapse because I had COVID and ended up with consequences, but with a lot of effort and prayers, today I am partially with limitations in my hands, I want to have better treatment for a better quality of life, and I know that in the United States everything is much more detailed and they give the best treatment in the world, I would like to know if you have any form of an exchange of treatment, as I have a dream of visiting the United States and taking part in the treatment of myasthenia gravis, I would really like to be able to go and get treatment there, could you tell me if there is any way for me to apply for a scholarship? study, oh please, I really want a better quality of life, I await your response and thank you
From someone with myasthenia gravis, thank you so much for making this video! It brings me some comfort knowing how truly knowledgeable anesthesiologists are. I’ve been under anesthesia countless times but it’s still always a little stressful with MG. I recently had a bad anesthesia encounter that left me with profound weakness upon waking up (and into the next day). We now know to have even more emergency medications and interventions ready in PACU as I wake up. Very glad to hear you guys are thoroughly educated on MG. Helps make these potentially scary and stressful situations feel a little easier.
Thanks for putting this together Max! Shout out to your dad for telling us about it 🙂 When I was first diagnosed, I had a thymectomy. My anesthesiologist did not take my MG and recent crisis into consideration. I was in "recovery" for over 24 hours and the surgeon wasn't sure I was going to wake up. I made sure that I personally speak to any anesthesiologist before surgery now. Once we are both comfortable - then we move forward. Congrats Dr Feinstein!!!!
Thank you for making this video. I have MG and have luckily avoided this issue entirely by insisting on local anesthesia for operations including repair of a completely severed Achilles tendon (pre-arthroscopic, circa 1990) and repair of a torn medial collateral thumb ligament (“skiers thumb”). I realize there are times when general anesthesia is unavoidable but I was quite surprised at the reluctance of the surgeons to just use local. There was huge pushback but I explained that I have MG and that the best way to avoid complications is just to use local. The operations were uneventful; I was completely awake and chatting with the doctors. This experience convinced me that there are lots of surgeries that could be done under local but that, as one of my surgeons put it, “we prefer our patients to be asleep”.
A lot of the time it just comes down to experience of the surgeon/anesthesiologists. Some do spinals, peripheral blocks and/or local anesthetic blocks for basically every single patient whom those arent contraindicated for(whether they’re doing it awake or going under GA-all the above are great for intraop and post op pain management for normal patients as well so they help decrease the amount of opioids needed). Where as some surgeons/anesthesiologists basically never do blocks bc they arent comfortable performing them due to lack of experience with it. Really comes down to training and how comfortable they are doing them tbh. Unfortunately for tendon surgeries, bc the surgeon needs to stretch the tendon. They need muscld paralysis bc it basically makes the muscle flaccid and thus is easier for them to stretch and reattach. Meaning they either have to do what you had done, which is a local block at they level of the surgery where the local anesthetic blocks action potentials to the msucle fibers (thus giving the same flacid paralysis effect) or you have to be tubed under GA with muscle relaxant on board (which MG pts are sensitive to so anesthesia generally dont want to paralyze yall unless they have to). Now a days local and peripheral blocks are far more common thanks to better and better ultrasound machines (and training on newer docs).
As a person with MG I’ve had the great fun 🤪of having to stay awake during procedures because the anesthesiologists felt that between my MG and medication allergies it was too dangerous to put me all the way under. Thank you for helping to educate people!
your brave. I had to do such and will never again. but have never had issue with anesthesiology. at least so far. but still will not do it again. yep, you brave.
On a tangent, a friend who had oral cancer surgery was failing to recover from the paralytic and remained intubated while a workaround was sought, so she experienced being paralyzed and intubated and aware, all at once.
Hello, I have been suffering from severe sinusitis for exactly 30 years. I am Brazilian, I am 45 years old and today they are treating me at the HC Hospital das Clínicas in São Paulo. I had a relapse because I had COVID and ended up with consequences, but with a lot of effort and prayers, today I am partially with limitations in my hands, I want to have better treatment for a better quality of life, and I know that in the United States everything is much more detailed and they give the best treatment in the world, I would like to know if you have any form of an exchange of treatment, as I have a dream of visiting the United States and taking part in the treatment of myasthenia gravis, I would really like to be able to go and get treatment there, could you tell me if there is any way for me to apply for a scholarship? study, oh please, I really want a better quality of life, I await your response and thank you
I am in my first year of studying medicine and I actually just learned this condition today for my exams... What a coincedence! Great video, keep it up.
I had a small procedure back in March and the anesthesiologist's eyes opened wide when I told him I have Lambert-Eaton Myasthenic Syndrome. All went well.
@@alexdenton6586 sensitivity to NDMRs, aka paralytic. Aka much nicer and easier to reverse the effects and get the OP breathing on his own again using sugammadex instead of glyco+neo (assuming he was tubed idk he said small procedure so maybe not). But basically what his syndrome is, is his body struggles to release ach (responsible for muscle contractions) due to defective pre-synaptic calcium channels. As a result people with lambert eaton tend to wake up very weak but get stronger as the day goes on (as those less effective channels are working all day eventually the ach builds up in the synapse and they feel stronger)
Hello, I have been suffering from severe sinusitis for exactly 30 years. I am Brazilian, I am 45 years old and today they are treating me at the HC Hospital das Clínicas in São Paulo. I had a relapse because I had COVID and ended up with consequences, but with a lot of effort and prayers, today I am partially with limitations in my hands, I want to have better treatment for a better quality of life, and I know that in the United States everything is much more detailed and they give the best treatment in the world, I would like to know if you have any form of an exchange of treatment, as I have a dream of visiting the United States and taking part in the treatment of myasthenia gravis, I would really like to be able to go and get treatment there, could you tell me if there is any way for me to apply for a scholarship? study, oh please, I really want a better quality of life, I await your response and thank you
@@alexdenton6586Hello, I have been suffering from severe sinusitis for exactly 30 years. I am Brazilian, I am 45 years old and today they are treating me at the HC Hospital das Clínicas in São Paulo. I had a relapse because I had COVID and ended up with consequences, but with a lot of effort and prayers, today I am partially with limitations in my hands, I want to have better treatment for a better quality of life, and I know that in the United States everything is much more detailed and they give the best treatment in the world, I would like to know if you have any form of an exchange of treatment, as I have a dream of visiting the United States and taking part in the treatment of myasthenia gravis, I would really like to be able to go and get treatment there, could you tell me if there is any way for me to apply for a scholarship? study, oh please, I really want a better quality of life, I await your response and thank you
Thank you for this video. I am on pyridostigmine. Now I understand why my neurologist was so emphatic that I must tell every Anesthesiologist that I do NOT have Myasthenia Gravis. I have an autoimmune condition where my immune system attacks my nerves. This impacts communication between nerves and muscles as well as nerves and glands.
Hello Dr. Max I find your channel very educating and amazing. I started following your contents. I am a RN assigned on a medical and telemetry unit and learning alot from your medical videos. Thank you for sharing your medical knowledge. More subscribers to you Dr. Max. I hope meet you in person in NYC someday :)
In a similar vein, I'd be really interested to see a video on if/how you need to alter your approach for other conditions that affect the muscles, such as those that cause spasticity, rigidity, weakness, tremors, and so forth.
For the most part its: use and LMA or a MAC and keep them spontaneously breathing the entire case if you cand. If not; if its a bigger procedure and you have to put a breathing tube in and paralyze then you want to use low dose MR’s amd just run them very deep (instead of using the MR to primarily keep them from moving use your gases/narcs/propofol to do so). Then use sugammadex to reverse rhe MR. In cases like people with MG you basically want to keep them spontaneously ventilating without a tube because if they meet whats known as leventhals criteria bc if they do then its more likely than not they will have to remain intubated in PACU until they’re deemed strong enough to remove the tube.
Some medical conditions that cause weakness you have to avoid certain drugs like muscular dystrophy, multiple sclerosis, etc. It depends on the condition and as a rule of thumb less is more when giving anesthesia. A lot of serious neuromuscular conditions can increase risk of acid reflux/aspiration too.
Dear Dr. Max, I want to thank you so much for sharing your heart and your knowledge with me. You will bless so many! I am an eight time Sero-Negative refractory, generalized Myasthenic since early childhood with PLEX being my main lifeline now. I also take Mestinon, Cellcept, and Prednisone. I am quite ill and chronically symptomatic. In April 2023 I had an AV-Graft placed. The nerve block did not work so general anesthesia was opted for. Sometime during surgery my diaphragm failed. As the surgery was being completed, I awoke to my entire body spasming from head to toe. Once these muscle spasms stopped, my brain was awake and I was hearing everything being said between the doctors and nurses. YET, my body was completely paralyzed! I could not open my eyes, move my limbs, or speak. In my head I am SCREAMING "I'm here, I'm awake, I can hear you, PLEASE, PLEASE help me!" But noone could hear me. The body spasms continued which is one of my weird symptoms. I awoke three days later in ICU, ventilated, and spasming . This was so incredibly frightening and physically devastating. I do not understand why this happened. Do Any thoughts? I am not asking for medical advice just needing to understand and mentally process the experience. My surgeon will not offer any insight. I am truly grateful to you and your heartfelt respect, understanding, and support of Myasthenia Gravis. If you do not mind, I will keep your loved one in my thoughts and prayers. God bless you and your wonderful career. You are a gem! 🦋
My father is living with LEMS, and is a colon cancer survivor. It's difficult to treat. It was his ophthalmologist who first diagnosed him. He has good days, and bad days.
Thanks v much Dr Max. I lost a good friend many years ago to complications of MG. So I try to keep learning more about it, this was very interesting. I'm not a physician but have a general interest in isoflurane etc hence I find your videos very interesting.
I think my grandma had that before she died, or someone she knew, I can’t remember exactly who had it (it’s been 14 years since she died), I just remember them talking about it a lot and how it affected certain medication and treatment choices, I never realized how it could complicate surgeries but it makes perfect sense, thanks so much for explaining this!
Fascinating video, thank you. My late father suffered from MG much of his life, and I've learned a lot about the condition over the years through my own research, but I learned some things here. I didn't realize neostigmine was used as an antiparalytic after anesthesia - if I recall correctly, it was one of the earlier pharmacological treatments for MG until a buffered form (Mestinon) came to market. Mestinon never did a lot for my dad, hence his heavy reliance on corticosteroids, which saved his life, but also hastened his death. My best to your loved one living with MG.
I learned so much about myasthenia gravis! I always learn a lot from you! You rock man, I’ve always wanted to be a anesthesiologist physician ever since I was a kid! I’m 33, i really enjoy donating to the anesthesiologist Foundation, since it was hard for me to go to college because of my cerebral palsy
MG warrior here--THANK YOU for this video! I've had 2 laproscopic surgeries in the past year and both anesthesiologists used Propofol, which I'm otherwise unfamiliar with. First surgery I had a fantastic anesthesia experience, second surgery my MG flared pretty badly afterwards but I reco ered okay. It's interesting to hear what these options are! Now I can have a more educated conversation with my anesthesiologist before my next surgery!
So its more likely the issue wasnt the propofol(propofol is actually one of our friends for MG pts, bc its one of the options we have in our pocket if we want/have to decrease the amount of paralytic we use-its referred to as running a deep anesthetic, basically we load up on more gas/propofol/narcotic and this can blunt your motor reflexes like how muscle relaxant does, but it does so outside the perview of the neuromusuclar junction where muscle relaxant works/MG exists) . The issue you had was more likely the paralytic used/how much/what they reversed the paralytic with/did they give you any other drugs that we routinely give that potentiate(prolong) the effects of paralytic . Bc it was laparoscopic surgery you were almost assuredly tubed and then given a muscle paralytic so they could get up under your abdominal muscle layer without those muscles tensing up/spasming. Problem is MG pts are SUPER sensitive to the muscle relaxants we give known as NMDRs. Meaning you want to run lower dosing than you would for a normal patient. Likely the second surgery they went heavier on the paralytic, you’re more sensitive to it(you require less for the same effect thus the excess was just sitting there waiting for its turn to work). Idk what reversal agents they gave or how much, you likely still had some on board which helped contribute to your feeling of weakness. The NMDRs we give block ach release pre synaptically, im sure you know this, how do we treat your MG while awake? You take a drug that helps increase your ach in the synapse in order to overcome your decreased amount of ach receptors. Thus if our NMDR is still semi-active and blocking the ach release into the synapse, you now have fewer receptors and less ach and thus the profound weakness you felt.
Thanks for doing this video. I have a friend with MG. Also I take pyrosrigmide off label for my pots (postural orthostatic tachycardia syndrome) and I had always taken it with food or if I had a minor procedure when I got home so I wasn’t sure if I could take it on an empty stomach so when I was scheduled for surgery w/ general anesthesia I contacted my cardiologist (he treats my pots) office on the portal asking about if it can be taken npo and I mentioned the surgery. Well one of his nurses responded advising me to skip it that morning because it could interfere with anesthesia but didn’t really explain why. Well now I know why!
Thanks so much for this very informative video. I will be having surgery for a recurrence of thyroid cancer, and I have MG, so this information is quite helpful. We have great docs here in Pittsburgh, and I’ll be sure to discuss my MG with the anesthesiologist.
@@kristinasnowflake Diaphragmatic involvement in combination with medical staff not really knowing what they were up against. Took a while (actually) ongoing to get asthma treatment optimised under the circumstances.
@@kristinasnowflake It sucked. I'm still pretty damn furious about the whole thing. Hellooo, YOU are the doctors, you should be able to manage this, there should be adequate inter-clinical communication (which is what failed spectacularly). It shouldn't have to be me googling to find that damn 90per cent oxygen sats is not good and I don't think that this is an asthma flare-up.
Have you ever done a video explaining how you monitor the heart during a long operation? The reason I ask is because I had a biopsy prostate recently, a very short procedure, however the anesthesiologist was very concerned with my murmur and stuck a very painful catheter in the back of the wrist and mentioned if the aorto was going to play up he would know in 10 seconds.
Thank you. I was just diagnosed last year. Apparently I had for a while and didn’t know until I had extreme dropping of the left eye lid-it went away in about 3 months-had gallbladder surgery and it came back with a vengeance. The I got diagnosed. Next year I will need knee replacement-going to use a spinal block. Then after recovery, onto the thymectomy!
Excellent information! It's a really tough disease to deal with on a daily basis. I speak from experience when I say that. Luckily, I am well managed and living a fairly normal life...thank God for modern medicine and smart people!
Thank you so much for this! I’ve been following your channel for several months and was delighted to see you talking about MG and anesthesia for MG Awareness month. I’ve had several bouts of respiratory failure following GA due to MG. Am having a procedure next month and am, to be perfectly honest, a bit apprehensive. And this is with a good anesthesia team who understand MG and have treated me before.
I have MG on a Thursday, I was having trouble swallowing, and I had a lot of mucus, that was so thick, that I had a hard time spinning it out, a lot of time I feel like I was drowning wake me up plus I could swallow, I told a nurse on Friday she told me to go to the emergency room, I went to the emergency room tell them I have a hard time waiting and swallowing and I feel like I was drowning because I can't swallow a lot in the mucus, they took an x-ray of my lungs and a Lyft test to check my lungs, did a blood test, and sed i was ok to go home, I couldn't talk very well, l did mansion I'm still having problems. I have to lay down a lot because, I don't have the strength to sit up too long, they had me in the waiting area too long, by the time I went in, I was wiped out, bay the time they told me to go home I was so wiped out, I just didn't want to complain because I just need to go home and lay down. It was 4:00 in the morning by the time I got home. I'm autistic, I know this isn't a place to complain, but I feel like I need to get it out of my system before I go crazy. I could only sip a little bit of water, if I tried to drink it would go up my nasal passage, I ate a couple of saltine crackers, sat,sun,mun,tus, on Monday I saw my PCP doctor, she gave me some antibiotic, and some allergy pills. They didn't help at all. On Tuesday I got my myasthenia gravis infusion, on Wednesday I was finally able to drink and eat again, still have a hard time, but it is better. My mg Dr practitioner I don't think she knows what she's doing, when I talked to her it's like, it's like talking to the wall, she said she's going to do something and never does it, I feel hopeless😢😢😢 I'm sorry if I bothered you.
Thanks for the info - very good to know. The only - and minor - addition I would add is the existance of MG flares, which are quite different for MG crisis. Thanks again.
Thank you for creating this easy-to-understand and informative video for Myasthenia Gravis Awareness Month! I live with Double-Seronegative Myasthenia Gravis (dSN-MG), confirmed via SFEMG testing. I'm also in long-term recovery from opioid addiction, which adds another layer of complexity. ❄💪
I also have double sero-negative MG too. Since the diagnostic antibody tests were negative, my daughter took a video when my face and eyes were acting up for the neurologist to diagnose me.
Wow.this was so educational. As a former nurse of 20+yrs I've never heard of the lambert one. One does not think about how u guys have to change the meds. Also I'm curious of how u know the pt is fully under and feels no pain? Thank u so much for your videos. Not sure why this took 2 mo to come in my feed.❤❤❤❤
thanks for info. we just found out members of family have this, having to have the major surgery. And another who suffered from muscle weakness for yrs night have it. Not sure what I will do. have muscle/nerve issues for years and now being tested. I do well considering my health. including beating later stage cancer recently with heart stents. however I was not put under on such and will NEVER do such again, being very traumatized by it. I can not do anything more than a deep shot now without being put to sleep. I simple just cant do it. Guess they will really have a problem with me going under from now on. Lucky though, I have never had an issue and have had many out and in patient surgeries. Hopefully they would still go by what works for me with caution. this was very informative. thanks for your time.
My last three times with anaethsisia, while diagnosed with MG, ended up in complications. With at least 6 days in ICU after each respiratory distress, with a 12 day stay in ICU after respiratory failure.
Chemo , Cyclophate, just finished (6 month) , am in partial remission , except for legs (literature says Cyclophate remission is good for 9 months in 75%, up to about 4 years, with 1/22 being in remission 10+ years)
I'm pretty sure I have had this for going on two years and it pure hell. I just need confirmation I have all the symptoms of it and it comes in flashes. My hand and arms go pretty much limp for days when I try to work I almost choke to death trying to eat. My words slur (not all the time) and I've had pneumonia three times in the pass year. And a bunch of other little tics. Like problem with using my face. I just want to see if anyone that has it can confirm that they have dealt with the same issues.
Thanks. I've just found out I've got MG N I'm nervous as have bad autoimmune disease anyway. Shake profoundly and I'm 48. So any peace of mind will help... 😊
@Max Feintstein could you talk about why it hurts in the chest/shoulder area when air is in the abdomen and how it can be minimized? I was shocked how bad it hurt after I had my gallbladder removed. The doctor said it was because they expand the abdomen with air or gas and it can get trapped above the breast area. Is this true?
My brother and I have a congenital form of MG and his heart stopped during surgery and he was down for 9 minutes, afterwards they said it had to do with the reversing agent but I'm not sure how the mechanism of that works 🤔
This is like hearing about aviation safety, every precaution is taken, even in instances of rare scenarios. Someone knows what happens, and what can be done, at the very molecular level. (Hooray for science! 🥳) Whenever someone has actually planned for most thinkable scenarios, it is very assuring and potensiallly helping many people mentally, who are scared of operations and anesthesia. So thanks for telling us this, even though we certainly haven’t heard about all these medicines and this channel is geared towards health personel. You are really educating us lay people - thank you very much! 🙂👍
My old roommate had myasthenia gravis, so I feel like I know more about it than the average rando on the street. I found this very interesting. Thank you. 😀
@@zpr6815 i dont think it will (anytime soon atleast) eliminate it from training. Bc in the cases of needed to emergently intubate someone, you may not have a cmac or a glidescope in the room and thus still need to know how to do good old fashioned DL with a mac/miller blade.
My blepharaplasty (eye lift for ptosis) was cancelled after it was scheduled months ago. It was because I have random unexplained O2 drops on a daily basis. Breathing room air it can drop into the 70s, and with 2L O2 supplement with a nasal cannula it can go into the 80s when I’m, talking, drinking anything, or just hyperfocused and still. Reading is exhausting. My heart and lungs check out fine. I have encephalomacia in 4 areas of my brain in an MRI done last year. I constantly feel on the verge of passing out. I have weakness and pain in my neck. There is a 6 month wait to see a neurologist 😢. I have POTS and EDS, but why is the burden on me for a diagnosis?
I was supposed to go in for a quick cataract procedure. My surgeon said we could do it in-office. The pre-anesthesia team canceled my procedure. I freaked out and got pretty upset with them. But once the anesthesiologist said "Look, you scare me, okay. Myasthenia Gravis is scary. I want you accessed and all my equipment and medications nearby. " Well, after he said he was scared, can't argue with that. I've now accepted that every surgical procedure I go in for is going to be an overnight and the whole 9 yards.
Same thing just happened to my Uncle. Supposed to be quick cataract procedure and now it's been many months and they've finally agreed to do it local anesthesia instead. Have you got yours done yet?
I had a colonoscopy, and the anesthesiologist acted like he had never heard of MG. My son has also been diagnosed. He had an EGD and had his esophagus dilated. His anesthesiologist knew all about it.
Thats wild. Maybe he was joking around? Idk anesthesiologists can be goofy. Good news is most of the concerns for MG pertain to muscle relaxant and paralytic. For a colonoscopy those arent gonna be used unless the patient cant maintain their airway or isnt trusted by the care to to maintain the airway. Which is usually only the case in the endoscopy suite if the patient is massively obese (talking 350+) or has some form of airway trauma/mass.
Hj good evening. Doctor. Am ASHFAQ ALI. Am in dubai long a time. Living j have a maysthinya gravis. 6 month a go. In hospital treatment 5 plasma and after discharged take. Medicine. medicine. Different typ
Opiod addiction/dependence tends to be time-dependent, intra-operative doses or even very short courses for post-operative pain will not lead to dependence/addiction.
What ^ said, but also spinals, peripheral nerve blocks, and local anesthetic blocks are becoming more and more common place as to help anesthesia and the PACU nurses decrease the amount of opioids they deliver for pain responses through out a case as well.
There are other anesthesia considerations for MS patients. Ie: you cant get a spinal for pain relief. But your considerations are different from that of MG
Wow. Just. Wow Thank YOU for this Information. I'm Just so, Wow. As a person who's never fallen into Twilight... Can you give me tips? I have legit been told by our giving you more medication than a person twice your size. But Nadda. Kinda worried. But, Thank you.
1) malignant hypothermia 2) June is pride month- only pointing out because logistic of going about awareness. Don't intend to open the can of bees about what gets a month and does not- the designations just get confusing for pretty much anyone trying to keep up.
I have MG that decided to bring cancer along for the party. There are very limited videos that talk about MG from a patient point of view. Anytime I have been in the hospital, I have told the doctors and nurses that if anyone has questions about MG to ask me. That’s the only way for people to learn and I’m more than happy to help in anyway I can. Thank you again for the video on MG!
Hello, I have been suffering from severe sinusitis for exactly 30 years. I am Brazilian, I am 45 years old and today they are treating me at the HC Hospital das Clínicas in São Paulo. I had a relapse because I had COVID and ended up with consequences, but with a lot of effort and prayers, today I am partially with limitations in my hands, I want to have better treatment for a better quality of life, and I know that in the United States everything is much more detailed and they give the best treatment in the world, I would like to know if you have any form of an exchange of treatment, as I have a dream of visiting the United States and taking part in the treatment of myasthenia gravis, I would really like to be able to go and get treatment there, could you tell me if there is any way for me to apply for a scholarship? study, oh please, I really want a better quality of life, I await your response and thank you
From someone with myasthenia gravis, thank you so much for making this video! It brings me some comfort knowing how truly knowledgeable anesthesiologists are. I’ve been under anesthesia countless times but it’s still always a little stressful with MG. I recently had a bad anesthesia encounter that left me with profound weakness upon waking up (and into the next day). We now know to have even more emergency medications and interventions ready in PACU as I wake up. Very glad to hear you guys are thoroughly educated on MG. Helps make these potentially scary and stressful situations feel a little easier.
Now I understand why it’s important to be honest and truthful about your health conditions.
Thanks for putting this together Max! Shout out to your dad for telling us about it 🙂 When I was first diagnosed, I had a thymectomy. My anesthesiologist did not take my MG and recent crisis into consideration. I was in "recovery" for over 24 hours and the surgeon wasn't sure I was going to wake up. I made sure that I personally speak to any anesthesiologist before surgery now. Once we are both comfortable - then we move forward. Congrats Dr Feinstein!!!!
Thank you for making this video. I have MG and have luckily avoided this issue entirely by insisting on local anesthesia for operations including repair of a completely severed Achilles tendon (pre-arthroscopic, circa 1990) and repair of a torn medial collateral thumb ligament (“skiers thumb”). I realize there are times when general anesthesia is unavoidable but I was quite surprised at the reluctance of the surgeons to just use local. There was huge pushback but I explained that I have MG and that the best way to avoid complications is just to use local. The operations were uneventful; I was completely awake and chatting with the doctors. This experience convinced me that there are lots of surgeries that could be done under local but that, as one of my surgeons put it, “we prefer our patients to be asleep”.
A lot of the time it just comes down to experience of the surgeon/anesthesiologists. Some do spinals, peripheral blocks and/or local anesthetic blocks for basically every single patient whom those arent contraindicated for(whether they’re doing it awake or going under GA-all the above are great for intraop and post op pain management for normal patients as well so they help decrease the amount of opioids needed). Where as some surgeons/anesthesiologists basically never do blocks bc they arent comfortable performing them due to lack of experience with it. Really comes down to training and how comfortable they are doing them tbh.
Unfortunately for tendon surgeries, bc the surgeon needs to stretch the tendon. They need muscld paralysis bc it basically makes the muscle flaccid and thus is easier for them to stretch and reattach. Meaning they either have to do what you had done, which is a local block at they level of the surgery where the local anesthetic blocks action potentials to the msucle fibers (thus giving the same flacid paralysis effect) or you have to be tubed under GA with muscle relaxant on board (which MG pts are sensitive to so anesthesia generally dont want to paralyze yall unless they have to). Now a days local and peripheral blocks are far more common thanks to better and better ultrasound machines (and training on newer docs).
As a person with MG I’ve had the great fun 🤪of having to stay awake during procedures because the anesthesiologists felt that between my MG and medication allergies it was too dangerous to put me all the way under. Thank you for helping to educate people!
your brave. I had to do such and will never again. but have never had issue with anesthesiology. at least so far. but still will not do it again. yep, you brave.
On a tangent, a friend who had oral cancer surgery was failing to recover from the paralytic and remained intubated while a workaround was sought, so she experienced being paralyzed and intubated and aware, all at once.
I have been that way once. It was so scary and frustrating.
Hello, I have been suffering from severe sinusitis for exactly 30 years. I am Brazilian, I am 45 years old and today they are treating me at the HC Hospital das Clínicas in São Paulo. I had a relapse because I had COVID and ended up with consequences, but with a lot of effort and prayers, today I am partially with limitations in my hands, I want to have better treatment for a better quality of life, and I know that in the United States everything is much more detailed and they give the best treatment in the world, I would like to know if you have any form of an exchange of treatment, as I have a dream of visiting the United States and taking part in the treatment of myasthenia gravis, I would really like to be able to go and get treatment there, could you tell me if there is any way for me to apply for a scholarship? study, oh please, I really want a better quality of life, I await your response and thank you
I am in my first year of studying medicine and I actually just learned this condition today for my exams... What a coincedence! Great video, keep it up.
I had a small procedure back in March and the anesthesiologist's eyes opened wide when I told him I have Lambert-Eaton Myasthenic Syndrome. All went well.
What is the problem with that syndrome ?
@@alexdenton6586 sensitivity to NDMRs, aka paralytic. Aka much nicer and easier to reverse the effects and get the OP breathing on his own again using sugammadex instead of glyco+neo (assuming he was tubed idk he said small procedure so maybe not). But basically what his syndrome is, is his body struggles to release ach (responsible for muscle contractions) due to defective pre-synaptic calcium channels. As a result people with lambert eaton tend to wake up very weak but get stronger as the day goes on (as those less effective channels are working all day eventually the ach builds up in the synapse and they feel stronger)
@@alexdenton6586😂 he knew he needed a lot of coffee for that one
Hello, I have been suffering from severe sinusitis for exactly 30 years. I am Brazilian, I am 45 years old and today they are treating me at the HC Hospital das Clínicas in São Paulo. I had a relapse because I had COVID and ended up with consequences, but with a lot of effort and prayers, today I am partially with limitations in my hands, I want to have better treatment for a better quality of life, and I know that in the United States everything is much more detailed and they give the best treatment in the world, I would like to know if you have any form of an exchange of treatment, as I have a dream of visiting the United States and taking part in the treatment of myasthenia gravis, I would really like to be able to go and get treatment there, could you tell me if there is any way for me to apply for a scholarship? study, oh please, I really want a better quality of life, I await your response and thank you
@@alexdenton6586Hello, I have been suffering from severe sinusitis for exactly 30 years. I am Brazilian, I am 45 years old and today they are treating me at the HC Hospital das Clínicas in São Paulo. I had a relapse because I had COVID and ended up with consequences, but with a lot of effort and prayers, today I am partially with limitations in my hands, I want to have better treatment for a better quality of life, and I know that in the United States everything is much more detailed and they give the best treatment in the world, I would like to know if you have any form of an exchange of treatment, as I have a dream of visiting the United States and taking part in the treatment of myasthenia gravis, I would really like to be able to go and get treatment there, could you tell me if there is any way for me to apply for a scholarship? study, oh please, I really want a better quality of life, I await your response and thank you
Thank you so much for bringing awareness to MG as a whole but also the anesthesia part of it. We appreciate you
Thank you for this video. I am on pyridostigmine. Now I understand why my neurologist was so emphatic that I must tell every Anesthesiologist that I do NOT have Myasthenia Gravis.
I have an autoimmune condition where my immune system attacks my nerves. This impacts communication between nerves and muscles as well as nerves and glands.
Would you mind sharing what it’s called? I am trying to learn more about conditions similar to Myasthenia Gravis.
Hello Dr. Max I find your channel very educating and amazing. I started following your contents. I am a RN assigned on a medical and telemetry unit and learning alot from your medical videos. Thank you for sharing your medical knowledge. More subscribers to you Dr. Max. I hope meet you in person in NYC someday :)
In a similar vein, I'd be really interested to see a video on if/how you need to alter your approach for other conditions that affect the muscles, such as those that cause spasticity, rigidity, weakness, tremors, and so forth.
For the most part its: use and LMA or a MAC and keep them spontaneously breathing the entire case if you cand. If not; if its a bigger procedure and you have to put a breathing tube in and paralyze then you want to use low dose MR’s amd just run them very deep (instead of using the MR to primarily keep them from moving use your gases/narcs/propofol to do so). Then use sugammadex to reverse rhe MR. In cases like people with MG you basically want to keep them spontaneously ventilating without a tube because if they meet whats known as leventhals criteria bc if they do then its more likely than not they will have to remain intubated in PACU until they’re deemed strong enough to remove the tube.
Some medical conditions that cause weakness you have to avoid certain drugs like muscular dystrophy, multiple sclerosis, etc. It depends on the condition and as a rule of thumb less is more when giving anesthesia. A lot of serious neuromuscular conditions can increase risk of acid reflux/aspiration too.
I have MG and am waiting on an operation. It has been made clear to me about the difficulty with my anaesthetic.
This is by far the most informative video for Myasthenia Gravis. I suffer a very difficult to manage generalised Myasthenia Gravis. Thank you 🙏
Dear Dr. Max,
I want to thank you so much for sharing your heart and your knowledge with me. You will bless so many!
I am an eight time Sero-Negative refractory, generalized Myasthenic since early childhood with PLEX being my main lifeline now. I also take Mestinon, Cellcept, and Prednisone. I am quite ill and chronically symptomatic.
In April 2023 I had an AV-Graft placed. The nerve block did not work so general anesthesia was opted for. Sometime during surgery my diaphragm failed. As the surgery was being completed, I awoke to my entire body spasming from head to toe. Once these muscle spasms stopped, my brain was awake and I was hearing everything being said between the doctors and nurses. YET, my body was completely paralyzed! I could not open my eyes, move my limbs, or speak. In my head I am SCREAMING "I'm here, I'm awake, I can hear you, PLEASE, PLEASE help me!" But noone could hear me. The body spasms continued which is one of my weird symptoms.
I awoke three days later in ICU, ventilated, and spasming . This was so incredibly frightening and physically devastating. I do not understand why this happened. Do Any thoughts? I am not asking for medical advice just needing to understand and mentally process the experience. My surgeon will not offer any insight.
I am truly grateful to you and your heartfelt respect, understanding, and support of Myasthenia Gravis.
If you do not mind, I will keep your loved one in my thoughts and prayers. God bless you and your wonderful career. You are a gem! 🦋
My father is living with LEMS, and is a colon cancer survivor. It's difficult to treat. It was his ophthalmologist who first diagnosed him. He has good days, and bad days.
Excellent video! Recently got tested for MG which turned out to be negative, still extremely interesting to learn about these sorts of conditions.
Thanks v much Dr Max. I lost a good friend many years ago to complications of MG. So I try to keep learning more about it, this was very interesting.
I'm not a physician but have a general interest in isoflurane etc hence I find your videos very interesting.
I think my grandma had that before she died, or someone she knew, I can’t remember exactly who had it (it’s been 14 years since she died), I just remember them talking about it a lot and how it affected certain medication and treatment choices, I never realized how it could complicate surgeries but it makes perfect sense, thanks so much for explaining this!
Fascinating video, thank you. My late father suffered from MG much of his life, and I've learned a lot about the condition over the years through my own research, but I learned some things here. I didn't realize neostigmine was used as an antiparalytic after anesthesia - if I recall correctly, it was one of the earlier pharmacological treatments for MG until a buffered form (Mestinon) came to market. Mestinon never did a lot for my dad, hence his heavy reliance on corticosteroids, which saved his life, but also hastened his death. My best to your loved one living with MG.
Great video! I would like to see a similar one for other musculoskeletal disorders like hypokalemic periodic paralysis or Duchenne Muscular Dystrophy
I learned so much about myasthenia gravis! I always learn a lot from you! You rock man, I’ve always wanted to be a anesthesiologist physician ever since I was a kid! I’m 33, i really enjoy donating to the anesthesiologist Foundation, since it was hard for me to go to college because of my cerebral palsy
MG warrior here--THANK YOU for this video! I've had 2 laproscopic surgeries in the past year and both anesthesiologists used Propofol, which I'm otherwise unfamiliar with. First surgery I had a fantastic anesthesia experience, second surgery my MG flared pretty badly afterwards but I reco ered okay. It's interesting to hear what these options are! Now I can have a more educated conversation with my anesthesiologist before my next surgery!
So its more likely the issue wasnt the propofol(propofol is actually one of our friends for MG pts, bc its one of the options we have in our pocket if we want/have to decrease the amount of paralytic we use-its referred to as running a deep anesthetic, basically we load up on more gas/propofol/narcotic and this can blunt your motor reflexes like how muscle relaxant does, but it does so outside the perview of the neuromusuclar junction where muscle relaxant works/MG exists) . The issue you had was more likely the paralytic used/how much/what they reversed the paralytic with/did they give you any other drugs that we routinely give that potentiate(prolong) the effects of paralytic . Bc it was laparoscopic surgery you were almost assuredly tubed and then given a muscle paralytic so they could get up under your abdominal muscle layer without those muscles tensing up/spasming. Problem is MG pts are SUPER sensitive to the muscle relaxants we give known as NMDRs. Meaning you want to run lower dosing than you would for a normal patient. Likely the second surgery they went heavier on the paralytic, you’re more sensitive to it(you require less for the same effect thus the excess was just sitting there waiting for its turn to work). Idk what reversal agents they gave or how much, you likely still had some on board which helped contribute to your feeling of weakness. The NMDRs we give block ach release pre synaptically, im sure you know this, how do we treat your MG while awake? You take a drug that helps increase your ach in the synapse in order to overcome your decreased amount of ach receptors. Thus if our NMDR is still semi-active and blocking the ach release into the synapse, you now have fewer receptors and less ach and thus the profound weakness you felt.
Excellent! Having surgery in 2 days and have MG. Comforting to know that Drs are very aware of this condition!
Thanks for doing this video. I have a friend with MG. Also I take pyrosrigmide off label for my pots (postural orthostatic tachycardia syndrome) and I had always taken it with food or if I had a minor procedure when I got home so I wasn’t sure if I could take it on an empty stomach so when I was scheduled for surgery w/ general anesthesia I contacted my cardiologist (he treats my pots) office on the portal asking about if it can be taken npo and I mentioned the surgery. Well one of his nurses responded advising me to skip it that morning because it could interfere with anesthesia but didn’t really explain why. Well now I know why!
Thanks so much for this very informative video. I will be having surgery for a recurrence of thyroid cancer, and I have MG, so this information is quite helpful. We have great docs here in Pittsburgh, and I’ll be sure to discuss my MG with the anesthesiologist.
Thank you for your dedication to the field of medicine and educating the public especially those w Myasthenia Gravis. It is a life altering disease .
Having (newly diagnosed) Myasthenia Gravis AND asthma since childhood turned out to be quite an interesting experience in all the wrong ways.
Oh no, was it problems with surgery? 😬 I also have MG and lifelong asthma!
@@kristinasnowflake Diaphragmatic involvement in combination with medical staff not really knowing what they were up against. Took a while (actually) ongoing to get asthma treatment optimised under the circumstances.
@@jneill Ugh that's awful, I'm sorry!
@@kristinasnowflake It sucked. I'm still pretty damn furious about the whole thing. Hellooo, YOU are the doctors, you should be able to manage this, there should be adequate inter-clinical communication (which is what failed spectacularly). It shouldn't have to be me googling to find that damn 90per cent oxygen sats is not good and I don't think that this is an asthma flare-up.
Have you ever done a video explaining how you monitor the heart during a long operation? The reason I ask is because I had a biopsy prostate recently, a very short procedure, however the anesthesiologist was very concerned with my murmur and stuck a very painful catheter in the back of the wrist and mentioned if the aorto was going to play up he would know in 10 seconds.
Thank you. I was just diagnosed last year. Apparently I had for a while and didn’t know until I had extreme dropping of the left eye lid-it went away in about 3 months-had gallbladder surgery and it came back with a vengeance. The I got diagnosed. Next year I will need knee replacement-going to use a spinal block. Then after recovery, onto the thymectomy!
Excellent information! It's a really tough disease to deal with on a daily basis. I speak from experience when I say that. Luckily, I am well managed and living a fairly normal life...thank God for modern medicine and smart people!
Thank you so much for this! I’ve been following your channel for several months and was delighted to see you talking about MG and anesthesia for MG Awareness month. I’ve had several bouts of respiratory failure following GA due to MG. Am having a procedure next month and am, to be perfectly honest, a bit apprehensive. And this is with a good anesthesia team who understand MG and have treated me before.
I have MG on a Thursday, I was having trouble swallowing, and I had a lot of mucus, that was so thick, that I had a hard time spinning it out, a lot of time I feel like I was drowning wake me up plus I could swallow, I told a nurse on Friday she told me to go to the emergency room, I went to the emergency room tell them I have a hard time waiting and swallowing and I feel like I was drowning because I can't swallow a lot in the mucus, they took an x-ray of my lungs and a Lyft test to check my lungs, did a blood test, and sed i was ok to go home, I couldn't talk very well, l did mansion I'm still having problems. I have to lay down a lot because, I don't have the strength to sit up too long, they had me in the waiting area too long, by the time I went in, I was wiped out, bay the time they told me to go home I was so wiped out, I just didn't want to complain because I just need to go home and lay down. It was 4:00 in the morning by the time I got home. I'm autistic, I know this isn't a place to complain, but I feel like I need to get it out of my system before I go crazy. I could only sip a little bit of water, if I tried to drink it would go up my nasal passage, I ate a couple of saltine crackers, sat,sun,mun,tus, on Monday I saw my PCP doctor, she gave me some antibiotic, and some allergy pills. They didn't help at all. On Tuesday I got my myasthenia gravis infusion, on Wednesday I was finally able to drink and eat again, still have a hard time, but it is better. My mg Dr practitioner I don't think she knows what she's doing, when I talked to her it's like, it's like talking to the wall, she said she's going to do something and never does it, I feel hopeless😢😢😢 I'm sorry if I bothered you.
This was so fascinating! Thank you for raising awareness about MG.
Thanks for the info - very good to know. The only - and minor - addition I would add is the existance of MG flares, which are quite different for MG crisis. Thanks again.
Thank you for creating this easy-to-understand and informative video for Myasthenia Gravis Awareness Month! I live with Double-Seronegative Myasthenia Gravis (dSN-MG), confirmed via SFEMG testing. I'm also in long-term recovery from opioid addiction, which adds another layer of complexity. ❄💪
I also have double sero-negative MG too. Since the diagnostic antibody tests were negative, my daughter took a video when my face and eyes were acting up for the neurologist to diagnose me.
@@allieg4011 Hopefully your diagnosis enables you to receive treatment, even though options are limited for seronegative MG
Another really good video! Wonderful information you passed along.
Thank you for posting. Really helpful education!
Muchas gracias max, muy educativo y muy buen video🎉🎉🎉😊😊
Wow.this was so educational. As a former nurse of 20+yrs I've never heard of the lambert one. One does not think about how u guys have to change the meds. Also I'm curious of how u know the pt is fully under and feels no pain? Thank u so much for your videos. Not sure why this took 2 mo to come in my feed.❤❤❤❤
sugammadex should be a standard of care at this point. neostigmine is garbage
New ASA guidelines basically mirror that sentiment.
I hate neostigmine sugammadex is wonder drug
@@MaxFeinsteinMD Is the drug becoming cheaper as it's utilization grows?
sugammadix
Does that still interfere with mestinon
thanks for info. we just found out members of family have this, having to have the major surgery. And another who suffered from muscle weakness for yrs night have it. Not sure what I will do. have muscle/nerve issues for years and now being tested. I do well considering my health. including beating later stage cancer recently with heart stents. however I was not put under on such and will NEVER do such again, being very traumatized by it. I can not do anything more than a deep shot now without being put to sleep. I simple just cant do it. Guess they will really have a problem with me going under from now on. Lucky though, I have never had an issue and have had many out and in patient surgeries. Hopefully they would still go by what works for me with caution. this was very informative. thanks for your time.
What use would procycylididine be in this emergency. When i had an cholinergic issue i was given procyclididine and it helped me within 5 minutes.
My last three times with anaethsisia, while diagnosed with MG, ended up in complications. With at least 6 days in ICU after each respiratory distress, with a 12 day stay in ICU after respiratory failure.
Chemo , Cyclophate, just finished (6 month) , am in partial remission , except for legs (literature says Cyclophate remission is good for 9 months in 75%, up to about 4 years, with 1/22 being in remission 10+ years)
Thank you for this informative video
thank you for your informative videos. Really helpfull while I am study exams, and need a break from reading or practicing mcq
I'm pretty sure I have had this for going on two years and it pure hell. I just need confirmation I have all the symptoms of it and it comes in flashes. My hand and arms go pretty much limp for days when I try to work I almost choke to death trying to eat. My words slur (not all the time) and I've had pneumonia three times in the pass year. And a bunch of other little tics. Like problem with using my face. I just want to see if anyone that has it can confirm that they have dealt with the same issues.
Thanks. I've just found out I've got MG N I'm nervous as have bad autoimmune disease anyway. Shake profoundly and I'm 48. So any peace of mind will help... 😊
@Max Feintstein could you talk about why it hurts in the chest/shoulder area when air is in the abdomen and how it can be minimized? I was shocked how bad it hurt after I had my gallbladder removed. The doctor said it was because they expand the abdomen with air or gas and it can get trapped above the breast area. Is this true?
What about Intravenous metoclopramide? I had a endoscopic videocapsule done 2 weeks ago. Thanks doc
Excellent presentation. Thank you.
My brother and I have a congenital form of MG and his heart stopped during surgery and he was down for 9 minutes, afterwards they said it had to do with the reversing agent but I'm not sure how the mechanism of that works 🤔
I have myasthenia gravies and Thyroid gravies disease and I had both removed
where do you shoot??
Are nerve blocks for rotator cuff surgery safe with MG?
This is like hearing about aviation safety, every precaution is taken, even in instances of rare scenarios. Someone knows what happens, and what can
be done, at the very molecular level. (Hooray for science! 🥳)
Whenever someone has actually planned for most thinkable scenarios, it is very assuring and potensiallly helping many people mentally, who are scared of operations and anesthesia. So thanks for telling us this, even though we certainly haven’t heard about all these medicines and this channel is geared towards health personel. You are really educating us lay people - thank you very much! 🙂👍
My old roommate had myasthenia gravis, so I feel like I know more about it than the average rando on the street. I found this very interesting. Thank you. 😀
Will videolaryngoscopy ever totally replace direct laryngoscopy? In both terms of usage and training
I imagine that it will
@@MaxFeinsteinMD do you think it could eliminate direct laryngoscopy from anesthesia training?
And which one do you use more frequently?
@@zpr6815 i dont think it will (anytime soon atleast) eliminate it from training. Bc in the cases of needed to emergently intubate someone, you may not have a cmac or a glidescope in the room and thus still need to know how to do good old fashioned DL with a mac/miller blade.
That's what I believe as well. Thanks! 😀
Can you please do a video on Dysautonomia?
My blepharaplasty (eye lift for ptosis) was cancelled after it was scheduled months ago. It was because I have random unexplained O2 drops on a daily basis. Breathing room air it can drop into the 70s, and with 2L O2 supplement with a nasal cannula it can go into the 80s when I’m, talking, drinking anything, or just hyperfocused and still. Reading is exhausting. My heart and lungs check out fine. I have encephalomacia in 4 areas of my brain in an MRI done last year. I constantly feel on the verge of passing out. I have weakness and pain in my neck. There is a 6 month wait to see a neurologist 😢. I have POTS and EDS, but why is the burden on me for a diagnosis?
Please do a video on anesthesia with inborn errors of metabolism!
Thanks so much, Dr. Max.
I have Myasthenia Gravis and i have been under anesthesia 4 times in 5 years
I was supposed to go in for a quick cataract procedure. My surgeon said we could do it in-office. The pre-anesthesia team canceled my procedure. I freaked out and got pretty upset with them. But once the anesthesiologist said "Look, you scare me, okay. Myasthenia Gravis is scary. I want you accessed and all my equipment and medications nearby. "
Well, after he said he was scared, can't argue with that.
I've now accepted that every surgical procedure I go in for is going to be an overnight and the whole 9 yards.
Same thing just happened to my Uncle. Supposed to be quick cataract procedure and now it's been many months and they've finally agreed to do it local anesthesia instead.
Have you got yours done yet?
I had a colonoscopy, and the anesthesiologist acted like he had never heard of MG. My son has also been diagnosed. He had an EGD and had his esophagus dilated. His anesthesiologist knew all about it.
Thats wild. Maybe he was joking around? Idk anesthesiologists can be goofy. Good news is most of the concerns for MG pertain to muscle relaxant and paralytic. For a colonoscopy those arent gonna be used unless the patient cant maintain their airway or isnt trusted by the care to to maintain the airway. Which is usually only the case in the endoscopy suite if the patient is massively obese (talking 350+) or has some form of airway trauma/mass.
Lupus and Sjorens and Fibromyalgia and MGD and Myasthenia Gravis ❤ pray for me
Hj good evening. Doctor. Am ASHFAQ ALI. Am in dubai long a time. Living j have a maysthinya gravis. 6 month a go. In hospital treatment 5 plasma and after discharged take. Medicine. medicine. Different typ
Remifentanyl is good, I used it several times in icu for intubation
Is there any procedure or a way to help to avoid patients to get adicted with opioids anesthesia? Have you already made a video about it?
Opiod addiction/dependence tends to be time-dependent, intra-operative doses or even very short courses for post-operative pain will not lead to dependence/addiction.
What ^ said, but also spinals, peripheral nerve blocks, and local anesthetic blocks are becoming more and more common place as to help anesthesia and the PACU nurses decrease the amount of opioids they deliver for pain responses through out a case as well.
Do patients with multiple sclerosis encounter similar problems with anesthesia? I have MS
No. MS has no association to the receptors described in this video.
There are other anesthesia considerations for MS patients. Ie: you cant get a spinal for pain relief. But your considerations are different from that of MG
Thank you!
Info. I never knew, I have General M G, Thank you
Max,
Have you graduated yet?
No. 3 weeks!
Congratulations in advance, Max!
@@MaxFeinsteinMD ❤️
"እንደ አባ ጊዮርጊስ ልንገርሽ አድምጪኝ"
ቃለ ሕይወት ያሰማልን ግሩም ዝማሬ ነው
Calm down, Ramses II.
How would you use general anaesthesia with hypokaelemic periodic paralysis with malignant hyperthermia?
7:26 nice dub, lol.
👀👀👀
I see Sketchy Pharm, I like the video
Love sketchy!
How come you don't do any live would love you too Anthony kaveh does ❤❤
Wow. Just. Wow
Thank YOU for this Information. I'm Just so, Wow. As a person who's never fallen into Twilight... Can you give me tips?
I have legit been told by our giving you more medication than a person twice your size. But Nadda.
Kinda worried. But, Thank you.
i didnt disclose it with mine i needed to get my airway fixed and i was willing to not wake up if that's how it had to be
Would the Covid vaccine have made my symptoms worse
Love
Davis Barbara Walker Kenneth Johnson Charles
1) malignant hypothermia 2) June is pride month- only pointing out because logistic of going about awareness. Don't intend to open the can of bees about what gets a month and does not- the designations just get confusing for pretty much anyone trying to keep up.
Ok
避難しよう！暑さ！
I disagree - to me, the worst pre-op condition is known malignant hyperthermia!
Iamreadinhuoespiot
June is also Groomer Awareness Month
Fortnite or pubg
Asaaarshijionthis