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Meeting Patients Where They Are

Like most neurologists, Dr. Charlene Hafer-Macko treats patients with a variety of neuromuscular conditions. Her focus, though, is myasthenia gravis (MG). It’s MG patients who provide her with the intellectual challenge she loves.

“I really like this population,” she says. “There are so many things you can do to help them stay in control of their disease. And this is a group that really uses the information they have to help themselves. Helping people through the journey is the part I find the most fun.”

As an associate professor of neurology at the University of Maryland School of Medicine, Dr. Hafer-Macko serves as director of the university’s multidisciplinary Myasthenia Gravis Center. This clinic pulls together all the services an MG patient needs in one coordinated package—including an infusion suite that provides intravenous immune globulin (IVIG), plasmapheresis service, and thoracic surgeons that focus care for thymectomy for myasthenia gravis.

“Our team is very well versed in myasthenia,” Hafer-Macko says. “So not only are they providing care, but they’re also monitoring for side effects and providing education and support at the same time.”

For Dr. Hafer-Macko, it’s the education and support part of working with MG patients that she finds most satisfying. Several years into her career, she realized that she wasn’t feeling fully fulfilled by her interactions with patients. She would assess their weakness and check their blood work and tweak their medications, but these exchanges with mostly stable patients felt flat. She needed something more.

She discovered that something more in the stories her patients told about their daily experiences. They reported, for example, that even when their double vision was controlled or they were back to walking normally, they still had trouble reading or watching TV, and they felt exhausted after a trip to the grocery store or just walking across the room.

“Even when many patients are well controlled, fatigue is an element that just stays with them,” Hafer-Macko says. “Fatigue is such a tricky thing. It’s something that is not often addressed effectively. So really understanding what’s driving that fatigue was something that I got very interested in.”

She teamed up with occupational, physical, and respiratory therapists to develop a better understanding of fatigue and the needs of MG patients. Together with this team, Hafer-Macko developed a toolbox of techniques for helping patients avoid or overcome fatigue and other challenges.

Listening to her patients’ stories has also helped Hafer-Macko become a better doctor.

“I learned how to ask questions differently, questions that gave me better data,” she says. “And then once I’d ask them differently, I could coach individuals on how to give me better information.”

When she would ask a question like, “Are you better,” for example, she found the patient’s response—“Yes, I’m better now”—didn’t provide much in terms of measurable outcomes. If, however, she asks about how long the patient can read before their eye symptoms make them put the book down, she has a benchmark that she can compare to a previous exam. It’s data that shows a meaningful response to treatment.

Stories of her patients’ fatigue also inspired Hafer-Macko’s research. She is part of a group at the Baltimore Veterans Association Medical Center that is exploring exercise, nutrition, and fitness in older adults. One of the things they have learned is that, because of their weakness, those with MG must work extra hard to accomplish even minor tasks like walking to the bathroom. This leaves far less energy for all other activities.

“It’s like every time they walk to the bathroom, they’re running a marathon,” Hafer-Macko says. “They have very little reserve. They’re just working very hard because of that weakness.”

Dr. Hafer-Macko has been recognized by the Myasthenia Gravis Foundation of America (MGFA) for her outstanding work with the MG community. She has served on the board of directors for the organization and currently serves on two of their committees.

Ironically, Hafer-Macko’s greatest inspiration is not a patient at all. It’s her mother. At 82, Charlotte Hafer still teaches dance—these days remotely by zoom. In 41 years of teaching elementary school during the day and dance at night, she never took a sick day. She continues to work as a math and reading specialist by day and teaches dance at night. As a devoted theater fan, her mother saved up her sick leave compensation so she could go to shows in New York City and in the Pennsylvania/Maryland/DC area to see shows. This year, Charlotte engaged the brave new world of Facebook to win a contest in which she was named Broadway’s Biggest Fan.

“She’s actually my inspiration,” Hafer-Macko says. “To deal with my mom and her medical hang ups, I’ve learned so much about taking care of people. You’ve got to meet folks where they’re coming from. They’ve got nuances, and that makes such a difference in working with a patient to find a care plan that will work well for them.” 


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Advocacy Health Information

Tips and Tricks for Managing MG

We recently spoke with neurologist Charlene Hafer-Macko, MD from the University of Maryland’s Myasthenia Gravis Center about ways myasthenia gravis (MG) patients can keep themselves healthy and stay out of crisis. Here are some of her tips and tricks:

Communicating about your condition with healthcare providers, especially in an emergency situation, can be a challenge.

  • Wear a medical ID bracelet, such as the MedicAlert, that identifies you as having myasthenia gravis.
  • Know what medications MG patients need to avoid, and carry a list of them in your wallet for easy reference.
  • Download the MyMG app from the Myasthenia Gravis Foundation of America. The app also has a list of medications to be avoided with MG.
  • Document your symptoms, treatments, and how they affect your daily life so you can have these data readily available when your doctor asks, “How have you been feeling?”
  • Always ask your healthcare provider or pharmacist if a newly prescribed medication is on the list of drugs MG patients need to avoid.
  • Use online resources to look up conditions and medications. Just be sure the source is reliable and informed by science.

Weak muscles can make breathing difficult, but there are things you can do to make breathing more efficient.

  • Use pursed-lip breathing, a technique in which you breathe out through puckered lips. See this demonstration.
  • Learn how to breathe into your belly by lowering your diaphragm. Learn how here.
  • Explore mindfulness practices that focus on breathing. This is also helpful for stress reduction. Find a guided exercise here.

MG symptoms tend to get worse with heat for many people. To avoid melting when it’s warm:

  • Take tepid showers. If you really like a hot shower, finish it off with a cold splash.
  • Avoid being out in the sun for long periods of time.
  • When the weather is hot, plan big activities for the cooler part of the day, and take advantage of air conditioning as much as possible. Ask your electric power company for a form that will ensure you are a higher priority for power when the electric goes out a storm.
  • Consider using a cooling vest if, for example, you want to sit in the hot sun for hours at the baseball game. Here is a sample of some available models.
  • Sporting goods stores also sell cooling towels and reusable, freezable gel packs.

Not getting enough sleep will make anybody more fatigued. For those with MG, insomnia can be related to corticosteroid use, anxiety, stress, and other effects of chronic illness. Good sleep habits can help. Here are some tips:

  • If you take prednisone, do so early in the day.
  • Schedule your bedtime so you get at least 7-8 hours of sleep.
  • Make a habit of going to bed at the same time every night and getting up at the same time each morning, even on the weekends.
  • Keep your bedroom quiet, dark, relaxing, and at a cool temperature.
  • Create a relaxing bedtime routine.
  • Ban electronic devices, such as TVs, computers, and smart phones, from the bedroom, and avoid using screens during the hour before you go to sleep.
  • Avoid large meals, caffeine, and alcohol before bedtime.
  • Exercise regularly to help you fall asleep at night.

And finally, Hafer-Macko advises that those living with MG watch their bodies, learn how their treatments affect them, and plan activities accordingly. For example, if you (or those you live with) notice that you start to slow down as you get closer to your next pyridostigmine (Mestinon) dose or IVIG infusion, that may not be the best time to schedule a big day with the kids that will use up a lot of your energy.

Similarly, if you take pyridostigmine, notice how it affects you. If it starts to wear off too soon, mention it to your doctor; you might need to adjust the dose. Also, be aware of scheduling high-energy activities like shopping or cleaning during times when your meds are wearing off.

The following organizations offer additional resources, including support groups, education, and research:


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Advocacy Patient communities

Paying It Forward

Ten years ago, Karon Faught started slurring her words and having trouble lifting her arms to blow dry her hair. She was only in her thirties, but some months later while at work, she couldn’t find the right words she wanted to say. She thought she was having a stroke. An MRI disproved this possibility, but it did nothing to alleviate the overwhelming fear she and her husband Jerry felt about what was causing these symptoms.

When she went to her neurologist, he had a list of conditions he wanted to test her for. Among them was not myasthenia gravis (MG).

“He said he was going to test me for MS and ALS and a couple other things,” Karon recalls. But nobody gets myasthenia gravis, the neurologist said, so I’m not even going to test for that.

Ironically, MG was the thing Karon’s primary care provider specifically suggested she be tested for. Also ironically, while she was in the office, the neurologist agreed to give Karon a magnesium infusion, a treatment she’d had before to treat her chronic migraine headaches.

What Karon and Jerry didn’t know at the time was that magnesium is one of a laundry list of drugs that makes myasthenia symptoms worse. That infusion persuaded the neurologist to do the blood test, because there in his office, Karon lost her ability to speak and move as a result of it. Three weeks later, the tests came back positive for anti-acetylcholine receptor antibody-positive MG (AChR MG).

This was just the beginning of a harrowing ride for Karon and Jerry, one they are grateful to the MG community in their home state of Texas for helping them survive.

“Ten years ago, there was really no good information about MG,” Jerry says. “Even at the top hospital in the region, one of the only hospitals in the country that was doing an MG clinical trial, people didn’t understand it. Their nurses were still giving IV Benadryl to MG patients, and their medical school was still teaching that kids couldn’t get MG. When we came into this, the best knowledge base was those that came before us.”

So when Karon was facing surgery to remove her thymus (a procedure that is often part of treating MG), she wanted to talk with others who had the disease and could help her understand what to expect from this major chest surgery. She and Jerry attended their first Myasthenia Gravis Foundation of America (MGFA) national conference that year and connected with the only MG support group in Texas, which was in Lubbock, about 300 miles from their home north of Dallas.

The group was led by Coleen Shinn. She and others from the group took the couple under their wing. And when Karon was in the hospital after surgery, they were a lifeline for Jerry who guarded his wife’s treatment from healthcare professionals who repeatedly tried to treat Karon with medications on that laundry list of drugs that make MG worse.

“After my surgery, Jerry was on the phone with Coleen almost 24/7, asking her questions and gathering information,” Karon says. “When the doctors wanted to give me a medicine, he would call Coleen and say, is this okay? And she would say yes or no. A lot of times it was no, don’t give her that medication, because she’ll go into crisis.”

Jerry chokes up when he remembers this time. “I owe a huge debt of gratitude to Coleen and Marvin and Lowell and Margaret and all the people in Lubbock who took us in. There’s no way I can explain how they helped us. There are just no words that can describe it.”

After Karon’s surgery, she and Jerry continued to attend support group meetings in Lubbock. They needed that companionship and the knowledge of others who lived with MG. But it was a five-hour trek, and they knew there had to be other MG patients closer to home. So armed with contacts they met at their second MGFA conference, they pulled together a support group in the Dallas-Fort Worth area.

Since then, the couple has created a nonprofit support network, MG Texas, whose only mission is to empower people by sharing knowledge about this rare neuromuscular disease. The organization now supports honorary Texans all over the world, and through the work of many others, there are now support groups in Dallas, Lubbock, Austin, San Antonio, Corpus Christi, San Angelo, and Beaumont. And because they live only 20 miles from the Oklahoma border, it was easy enough to restart the groups in Oklahoma City and Tulsa after the MGFA reorganization. They’ve also started, MGKids.com, the only nationwide MG support organization for children with MG.

“There are so many fears when a person comes into this,” Jerry says. “If we can alleviate any one of those fears to help them get to the next stage of the healing cycle, then that’s really what drives us.”

This support group network has also been part of the healing cycle for Karon and Jerry.

“The support group has helped us get through this,” Karon says. “Helping other people has helped us heal from what we’ve lost. Having a diagnosis like MG, you have to look at life a little bit differently and make some adjustments. But when you help other people, you don’t think so much about what you’re going through.”

“I’ll be honest with you, at the beginning, I was angry, Jerry says. “And the only way to battle this disease that we can’t fight is to educate so that it doesn’t hurt others. That was the why we started the support group in Dallas. The bonus was, if we get more people in the group, it will help us.”

But healing the fear and anger is only a part of Jerry’s motivation.

“There’s a debt we have to pay forward,” Jerry says. “We’re going to have it for a long time. And that’s really what drives me.”