Yes but it say specificly say to whom it is to "first do no harm" to, us or themselves(oops sorry there's my sarcasm rearing its ugly head again, I might get into trouble soon!!)

in fact it is not either-or, as once you mange to truly follow this dictum and be there for your patient, admitting your (and your profession's) abilities and dissabilities, and becoming true partners in fighting disease, then there are very few things that can lead to such a feeling of satisfaction.

this is from a book about Hippocrates -

Medicine must try to preserve or restore the supreme good and divine: health. "Health, the most venerable of the blessed divinities, would that I might pass the rest of my life with thee! … if there is in fact, any charm in wealth , or in children, or in the royal power that makes man equal to a god…that everything flourishes, that the company of the graces shine; but without thee, there is no happiness."
The lofty ideals of the Hippocratic treatise are altogether exemplary; and on the relationship between the physician and the patient, their humanity is also quite exceptional. And so it is not surprising that, having first made a deep impression upon contemporaries, they should have become the bible of the physician over the succeeding centuries. In our days, despite progress of medical sciences, which has once and for all turned its back on Hippocrates, they still possess a freshness… they offer rich grounds for reflection for anyone who wishes to become acquainted with the earliest roots of humanism.
The Hippocratic message concerning the foundation on which rest the relations between physician and patient may be summed up in a famous maxim: "as to disease, make a habit of two things- to help, or at least do no harm." Here Hippocrates clearly asserts that the purpose of medicine is to protect the interests of the patient. But the physician's unique point of view serves to lend nuance to what was to become a more dogmatic position with the philosophers. Because the injunction to "do good" represents an ideal that the physician cannot always attain, he adds "or at least do no harm" failing to be useful, the physician must not worsen a patient's condition through an untimely intervention.

The dialogue between the physician and the patient:
… The originality of the Hippocratic manner of speaking lay elsewhere. It consisted in initiating a dialogue with the patient for the purpose of collecting information about the diagnosis or prognosis of the illness, or the course of treatment… to know how to question a patient was indispensable, but it was also necessary to know how to listen…the patient's response served as a guide for the physician in the course of treatment-but only on the condition that the physician knew how to interpret it. Where he did, an attentive dialogue came to be established that marked the beginning of authentic partnership between physician and patient in fighting illness. "The art had three factors, the disease, the patient and the physician. The physician is the servant of the art. The patient must co-operate with the physician in combating the disease."

alice

Rach,

I hope that you get some answers during your next appointment with your neuro.. I wish you lots of luck, and I wish the neurologists you see a full head of marbles (as in, they make the correct diagnosis)!

I just wanted to comment on a couple of things. During an MG conference, the experts said that one of the reasons doctors are so hesitant about giving an MG diagnosis with out any black & white results, is because the meds that are prescribed are very serious, and can be life threatening. So they don't want to put someone on, say prednisone which can be very difficult to get off, or wean down. And some people end up having to be on it for the rest of their life because their adrenals don't want to wake back up. Kidney damage from some of the immuno suppresants can cause kidney damage. And once that happens, the kidneys don't re-heal themselves. It's permanant. IVIG can damage the kidneys. There are just so many health problems that can be created from some of these meds.
Call your neuro, and ask them if they would like you to wear yourself out, so they can test during a weaken state. My neuros always wanted to test me during the weak periods, and even put me through the mill before the Tensilon test. So give a call, and ask them. They'll be able to help you.
If you are in a weakened state, and have the emg, chances are it will show up easier than when you're well rested.
Best of wishes
Love Lizzie

Lizzie,

This is perfectly correct, and I do not believe that any patient in his/her right mind would want to recieve such treatment needlessly.
yet, one can't ignore the fact that those "black and white" results do not exist in neurology. and even more precise fields of medicine are not an "exact science". and it is said that if you do not want to miss any case of acute appendicits, you would have to be ready to have some "white appendixes"taken out.
the "objective" tests that they use to diagnose this illness (and many other neurological diseases) have significant limitations.
and although many neurologists and patients think that if they could only do the test under the proper conditions it would "work", in reality this just doesn't happen. (because of all the reasons that were mentioned).

this is an answer I recieved from a reputable internet site-

Question:
is it possible to have a normal SFEMG during a myasthenic crisis or near-crisis. eg-when there is severe generalized weakness and respiratory difficulties with a concomitant drop in the MIP and vital capacity. if not what is the possible alternative diagnosis. and what further tests need to be done, in order to verify it.

Answer:
No, it is not possible to have normal SFEMG in muscle weakened by MG. So if you have generalized weakness and a weak muscle showed normal SFEMG results, the cause is something else. There are other possibilities but it is not at all a good idea for me to speculate over the internet. The key is to work directly with an experienced neuromuscular specialist. An accurate diagnosis requires a solid doctor patient relationship. It is also always fine to get a second opinion.


I have not yet been able to recieve an answer from any neurologist I talked to as to what that "something else" is. All I can tell you, based on my own experience the only "something else" that they have in their differential diagnosis is some ill defined emotional problems, that only they can "see". as neither you, your family and friends, or even excellent psychiatrists are capable of understanding such complex emotional problems.

further more, I am not aware of any test to which I (or any other reasonable physician) could give such a categorical answer.
if you asked me -could a patient have a myocardial infarction with a normal EKG? I would answer that this is very unlikely, but indeed possible.
if you asked me- could you have a patient with leukemia and a normal blood count? I would give you the same answer.

the SFEMG is a surrogate marker or a very different biological event.
all it tells you (if it is done correctly and under the right conditions) is that there is a normal conduction of the electrical signal from the nerve to the muscle. it gives you no information what so ever, as to how this electrical signal translates into the muscle contraction.

it is true that in most patients the curlpit is in this process and they do have an abnormal transmission of the electrical signal, but what about the minority that don't? it is not only that they do not recieve immunosupressive treatment, they are deprived of any treatment what so ever, and treated with disrespect (to say the least).

further more, some patients that have diagonstic SFEMGs do not have an autoimmune disease and do not require immunosupressive treatment, as they have a genetic defect as the cause of their illness.

and there are quite a few reports in the medical literature of patients who recieved agressive immunosupressive treatments and were later found to have CMS.

medicine is not an exact science and neurology is in the most un-precise side of the spectrum. myasthenia is not the best understood autoimmune disease, and not the most easy to treat. it would be nice if it was, but it's not.

and trying to "fit" patients into "black and white" boxes, ignoring their clinical symptoms, can only lead to much more significant mistakes.

this is at least my oppinion.

alice

Hey Alice,

This might be a really weird question, but where would the needle be inserted for SFEMG if a person has respiratory weakness? I know that for me, they put the needle in my forehead because I had facial weakness (or maybe they were checking my ocular muscles, not sure...I didn't have ptosis or dv at the time the testing was done, though)...This is why I think that it would be odd to use SFEMG in a case where a person has mainly respiratory weakness, just because I have no idea where they'd put the needle...I'm prollly totally missing something....But it seems that if that is the case (that it wouldn't be possible to measure that sorta weakness with that sorta test), they should base the diagnosis on symptoms, response to meds. and/or blood tests (if the weakness is isolated to the breathing area)...

As to whether you can have a heart attack and have a normal EKG, I witnessed this with a patient in the next bed to me back in february during the admission where I met the lovely lady Dr who practiced "third world" medicine!

A gentleman in the next bed to me (yes it was a mixed ward and I was assualted by a male patient with dementia whilst sleeping - god bless the NHS!) came into hospital with chest pain that was radiating down his left arm. His EKG was normal and he was on the emergency medical unit for observation. The first consultation was at 8am - I was being nosey and listening! The Dr told him he hadn't had a heart attack and it was probably indegestion.

Then at 9am they came racing back to the bed. One of the medical students had drawn blood the night before. The results had come back in and showed an enzyme present in his blood that would only be there if he had had a heart attack. The patient was then told he did indeed have a heart attack the day before and would be seeing the cardiologist later that day. It was only due to the person ordering the blood test the night before that this man wasn't discharged.

Ok so back to topic. I am planning to try and ensure that Im in a weakened state for my SFEMG. Its going to be difficult as the appointment is 3 hours away by car. But I plan to try and repeatedly move my arms and legs before hand to see if it provokes a response!

Thanks to everyone who has posted on this thread.

Love
Rach

Hi Nicky,

sorry for missing your question before.

your question is not weird at all, but actually very smart and reasonable.

and you are right that it is somewhat odd to examine the occular muscles of someone who is mostly having respiratory problems, but this is in fact what they do, as they can't do a SFEMG of the respiratory muscles.

they can do a RNS of the diaphragm, but the accuracy of this test is quite low, and requires a very experienced person to do that.

they can also measure the force generated by the diaphragm directly, using magnetic stimulation of the phrenic nerve (the nerve that innervates the diaphrgm). but this is only done in very few places in the world, requires a specialized center with expertise in neuromuscular respiratory problems, and is a somewhat invasive procedure.

alice