What to expect from a pacing clinic appointment?

Pacing check appointment

by Repero - 2023-08-11 17:00:17

Thanks Gemita, here is my experience.

My local hospital is in the South West part of the UK. I went for my first, four week, pacing check a week ago. It was great. The two Physiologists were super-knowledgeable and spent a whole hour with me trying to get things right. This included three high-speed dashes around the corridors and stairs to get my heart rate up so that they could interrogate the PM to check on how it was beating my heart. Ended up in them switching off the Biotronik rate-response algorithms (CLS etc.). They were not needed as I only have complete block, my sinus node is good. They had been switched on at the time of implantation and were basically just interfering with my own sinus rhythm. Things are a lot better now they've been switched off.

The Physiologists were very attentive to my questions and, once they discerned that I had done my heart homework (haven't we all!) they answered all my questions in detail. I have nothing but praise for them. They said that they found that patients would have a better experience with their PM if they fully understood what it was set up to do - that was their mission. They stressed their continuing availability by telephone in case of need. If a face-to-face appointment for further changes was needed, it would be arranged within days - otherwise future reviews would be conducted remotely using the uploaded data. Very supportive and reasurring. Sadly, though. I did not get any written record of what was done. I should have asked.

Just be ready with intelligent questions, be polite and alert, and I am sure your chances of a similar experience will be high. I hope so!

pacing clinic

by new to pace.... - 2023-08-11 17:36:44

I do not remember what happened last year except the puck would not stay on and i had to hold it against my pacemaker. I will be able to hopefully answer all your questions,after Aug24,2023.  As that is my yearly in office pacemaker check..  I did jot down some questions that you and others have offered me from my query of June 18-23,2023.

new to pace

new to pace and Repero

by Gemita - 2023-08-11 19:33:54

New to Pace, you sound very organised and well prepared and I hope your pacing check on 24th August goes really well and no nasty surprises are found.  I don’t have to have an up to date annual pacing check for this thread, I am more than happy for you to answer this post based on your previous in clinic pacemaker check if that would be easier although up to date information would be welcome too.

Repero, your hospital in the South West sounds exceptionally good but then you are a good student.  I agree it is essential that we do our homework before we attend our appointments at least on one or two essential questions to ask, so that we can have a meaningful conversation with the physiologist.  It is all so technical though and a real study for most of us.  

I can remember my Electrophysiologist writing to my GP telling him that I had done some research on one of my Settings. I think the EP and GP were both impressed.  I didn’t really know what I was talking about, but I managed to get my message across why I wanted one of my settings turned off which my EP agreed with.  I am not sure about always being alert, but I am always polite and nice to everyone and that always works for me.  

I am not surprised you were unable to get any written records on the spot.  Some UK members have taken a USB stick to their appointments (in the past) and then asked for a complete copy of their pacemaker records.  I am not sure that they are still allowed to do this.   I have to apply “formally” for my records, and that can take months to arrive.  I would always ask though when any settings are changed or you could get this information by emailing your Pacemaker Clinic.  I always like to get it in writing.

Finally my current technician who I always see keeps telling me to “leave these technical matters to him”.  I have to firmly keep telling him I enjoy trying to understand what is set up in my pacemaker.  Perhaps they think I am too old for all of this and they wouldn’t be so wrong either.

My experience

by Lavender - 2023-08-11 21:45:55

- Is your doctor or cardiac technician willing to explain the basic checks they do and are they willing to answer any questions you might have about these? 
yes I am seen at my regular cardiologist office every six months.  I see the tech first. I sit on a chair. They wave a sensor above my pacemaker which connects me to their laptop. They test each of my three leads. At my last pacemaker interrogation, the cardiologist said I lost my pulse briefly during the right lead check-so he ordered them not to check the right lead anymore when I go. 

I can ask questions. They explain nicely. The whole test only takes maybe five minutes total.

- If changes to your settings are made, does your doctor or technician tell you about these changes and explain why the settings are being adjusted?

I only had a few setting changes in the two and a half years that I have had a pacemaker. The tech tells me what they recommend and they get approval first from the cardiologist.

- Does your doctor or technician share with you the overall findings of your pacemaker interrogation, particularly if there were any “events” like a very fast heart rate or new arrhythmia detected?

I always ask if there have been any events and the tech tells me immediately what things have happened and how much I am pacing.

- Are you offered a copy of your pacemaker downloads at the time of your appointment, or told how you could obtain a copy of your data? 

I am not automatically offered a copy but since I realized I could have that, I always ask and the tech prints and hands it to me. 
After the tech is done, the cardiologist comes in, listens to my heartbeat and asks if I have any questions.  The whole appointment takes about twenty minutes including both the tech and cardiologist portions. 

Comment on Gemita's last

by Repero - 2023-08-12 04:41:36

"Leave these technical matters to me" is the worst sort of condescending put-down you could get! Horrifying! I hope that that attitude is the exception.

My experience was the exact opposite and they were keen to explain everything in as much detail as time allowed. But, thinking back, I would stress that this was always in response to my questions. So it comes back to your point "I agree it is essential that we do our homework before we attend our appointments at least on one or two essential questions to ask, so that we can have a meaningful conversation with the physiologist.  It is all so technical though and a real study for most of us."

I mulled over what I was going to say during the days leading up to the appointment, and tried to boil it down to just the one or two questions that I really wanted answered - rejecting anything irrelevant. I anticipated a much shorter appointment than I actually got, but the preparation stood me in good stead and the conversation expanded nicely. I agree it's technical, but I would guess that many of us feel strongly motivated to understand what is happening to us - it's our heart, after all and the effort is worth it, IMO.

If you don't ask questions, they assume you are not interested.

Lavender and new to pace

by Gemita - 2023-08-12 04:56:35

Lavender, thank you for your account of what happens at your pacemaker check.  You clearly have a caring team monitoring you and I like the fact that the cardiologist returns to listen to your heartbeat AFTER the technician has checked your device.  That seems almost like a safety net to make sure that any checks or settings changes have not inadvertently adversely affected your heart beat/rhythm which I suppose could happen.  Even if that isn’t the reason for your cardiologist to check your heartbeat before you leave, it shows they are more than caring.  

I was impressed that you are able to receive a print out on the spot of some of your data.  I will ask my technician if he can print me a few of my essential pacing check results when I am next there and see what happens, although I think he writes up the “summary report“ after I have left.  I do like my technician who explains things to me, but I do wish he would stop telling me not to “worry” about the technical stuff.   I have yet to convince him Lavender that I am actually “interested” in the technical stuff and why not?

new to pace, apologies, I have just noticed your highlighted I do not remember what happened last year except the puck would not stay on and i had to hold it against my pacemaker.  I will patiently await your details.  Thank you again

Repero

by Gemita - 2023-08-12 05:38:25

Thank you Repero.  It certainly feels like a put down when the technician says I should leave the technical stuff to the experts.  I think it started badly because despite being told by this particular technician that one of my Medtronic settings NCAP (non competitive atrial pacing) could not adversely compete with atrial preference pacing (APP), it turned out that this was not always the case, at least for me, and that the beneficial effects of APP were being adversely affected (or undermined) by having NCAP switched ON.   

I asked my EP whether we could trial switching NCAP OFF.  He listened and he agreed.  The effect was immediate and there was a noticeable improvement in my symptoms, so I felt reassured.   The technician said rather unkindly afterwards, that it was a “red herring” and my real problem was the Atrial Fibrillation that needed better control (an ablation).  I begged to differ and suggested that I was looking for less invasive treatments for the initiation of my AF (the premature atrial beats) and I wanted to experiment with my pacemaker settings first before having an ablation.  I don’t think he liked my answer.

I agree completely with you, with time constraints in the NHS, it is vital to only ask one or two important questions, to be sure that they can be covered adequately during our appointments, since in my experience going in with a long list of questions, will put any doctor off.  But as you say they can only respond effectively if we ask the appropriate questions.  Any question has to be really thought through carefully and this is not easy when we are trying to deal with a technical subject like electrophysiology, arrhythmias, settings. I think we should do a post on how to “effectively” ask the right questions to satisfy our need for answers.  Now there is a challenge for one of us Repero?

Accept your challenge!

by Repero - 2023-08-12 07:24:16

I am only a newbie, so feel presumptuous in even attempting to rise to Gemita's challenge, but that has never stopped me before! I am willing at least to start the conversation about "how to effectively ask the right questions to satisfy our need for anwers". Your turn next!

I have already been told that one of the recurring themes on this forum is - "it's about how you feel". The technical complexities of pacemaker technology are truly daunting, but you don't need to know it all. I would suggest that one way of homing in on the most effective question for you to ask during your all-too-brief encounter with the experts would be to clearly identify the one aspect of how your PM makes you feel that worries you the most. Alternatively, the starting point may not be something you are actually, physically feeling, but something that you have read about, some possibility, that you worry may happen to you. Wherever it comes from, we could call this "our main point of concern". This is all pretty obvious, and I imagine most people would already know what this is for them, personally.

I think a beneficial next step would be to start to do some reading and Internet searching to see what others who have the same concern have said about it. Again this is obvious. The main point is that we are quite likely to be able to identify areas of PM settings, or problem areas with our own particular make and model, which might have a bearing on our main concern. If we can get to this point, we will have drastically narrowed down the amount of technical study we need to do to get some insight into what questions to ask.

Another very important area of basic preparation, again in my opinion, is the general anatomy of the heart. There are some great animations and tutorials on Youtube to explain about atria, ventricles, sinus nodes, etc. If you have some idea of what the normal heart process is, you will be much better placed to understand what you are told at your appointment, as well as helping you know what questions to ask. This is technical in a different sort of way, but I found it quite fun.

As an example of how this line of thinking might work, here, briefly, is my experience. My diagnosis was complete heart block. My basic heart homework taught me that this is a failure in the electrical conduction pathway in the upper part of the heart. The consequence is that beating requests from my nervous system, at the Sinus Node towards the top of the heart, were not being passed on to the important beating chambers, ventricles, below. The main function of my PM would be to bypass this block and make sure the signals were reaching the correct part of the heart.

I did some general reading about PMs. My "main point of concern" was that the software would impose a limit on how fast it was prepared to beat my heart, and thereby limit my ability to do vigorous exercise: Morris Dancing in my case. In the four weeks following implantation, as I undertook fairly vigorous walks, I did indeed notice a cap on my heart rate at about 120 bpm associated with breathlessness. This increased my main concern, but also gave me a focussed area for further reading on my own Biotronik Enitra 8 pacemaker.

After all this, I went to my first pacing check armed with the following:

1. Clear definiton of "my main point of concern".

2. Basic knowledge of heart anatomy, function and terminology.

3. Knowledge of, and evidence for, the existence of an imposed upper rate for heartbeating.

4. First hand experience of physical problems (breathlessness) associated with this.

5. Some knowledge of other PM settings and functions that might also have an impact on my main concern.

6. A ready formulated question: "I am afraid that the upper heart rate limit will prevent me from enjoying my Morris Dancing hobby, can it be raised?"

In the event, it all turned out to be somewhat more complicated than I had imagined. But it was clear to the physiologist that he could engage in a meaningful conversation with me on these issues. We got it sorted entirely to my satisfaction.

The issue will be different for everyone. Gemita, for example, may have as her "main point of concern" the need to explore PM settings that would enable it to fully or partially control AF. All the numbered points, 1 to 6 above, would also apply in her case.

Does this contribution get us any further forward, or is it all too obvious anyway?

Pacemaker checks

by Aberdeen - 2023-08-12 08:30:11

I have a regular annual appointment at the cardiology department of my local hospital.

The technician explains what he is doing and answers any questions I may have. I know that I am paced 100% of the time.

As far as I know no changes are made to my settings.

At my most recent appointment in June the technician said there were 2 bouts of arrhythmia where my heart had exceeded 100 beats per minute. It was only for approximately 4 seconds. I was given the specific dates but I couldn't say that I noticed anything unusual on those dates.I haven't been offered a copy of the pacemaker results. I will ask next time.

Excellent Repero

by Gemita - 2023-08-12 08:32:54

You were more than ready for the challenge!  Thank you for that excellent contribution.  I will digest it with my meal and respond later.  Clearly symptoms are important to discuss since all doctors work with symptoms, but we have to dig deeper for the causes of our symptoms, since the purpose of any visit is to get “effective” treatment.  I think it would be helpful to raise this question in a new post because it is so important and gets to the heart of the matter!  Until later, thank you again.  What a great response

Aberdeen

by Gemita - 2023-08-12 11:01:38

Aberdeen, thank you so much.  You are doing well to only require one annual check a year after all you have experienced.   I wouldn’t be too concerned about a 4 second run of a heart rate exceeding 100 bpm, although it would be interesting to know whether the arrhythmia was of atrial or ventricular origin?  The fact that you felt nothing was as excellent sign that your heart is not under any stress, so your pacing must be really suiting you.  So reassuring that everything is working as it should.  I hope you continue to have excellent results.

Repero

by Gemita - 2023-08-12 11:08:10

You are clearly picking up on “what is important is how we feel” (our symptoms), and these should be the focus of any discussion with our technician/cardiologist/EP.  Indeed I once went into my appointment only wanting to know what was seen in my records and my EP quickly returned the focus to “how I was feeling, what symptoms I had”.  I realised quickly that I had started on the wrong foot, had asked the wrong question and it was leading nowhere.  I felt very frustrated because I was interested in finding out my highest heart rate recorded for the period, the arrhythmia seen and duration of the arrhythmia event.  I was disappointed when the EP told me he was not interested in my numbers, events, arrhythmias but more interested in how I have been doing, how well I had “tolerated” my symptoms during the period of monitoring?  Based “on my symptoms” he would know which treatments to recommend.  In the absence of symptoms he would be inclined to leave well alone.  So the focus of any appointment needs to be on our symptoms primarily.  Our symptoms will be our passport to getting “effective” treatment.

The problem with homing in on the most effective question to ask is that most of us don’t know where to start or where to finish.  We don’t always know where our symptoms are coming from, whether they are mostly due to our heart condition or due to our pacemaker which may have worsened our symptoms. To always be told that our pacemaker is working as it should is unhelpful and often confuses us further and does not help us with our symptoms.  The pacemaker may well be working fine, but is it “sensitively” set up to suit our individual requirements?  This is an important first general question for us all and then we can dig deeper later in future appointments/discussions, to find the exact setting, pacemaker function as well as other causes for our symptoms.  You were lucky to get a quick fix Repero, most of us are not so fortunate in finding a helpful doctor/technician, but clearly doing your homework paid off.  I agree, we certainly don’t need to know it all, or to ask every question during one appointment, since to try to do so would indeed be daunting.

Thank you so much for all those excellent tips of where to go for information.  I wanted to start a Settings Clinic on here once but we would have to find members with expertise of their own settings and settings in general who would be willing to commit to answering some questions on a regular basis for it to work.  I know we can all ask questions whenever we like but to have a regular clinic and dates when these would run, would encourage members to log on, ask questions or give answers.

You are correct, my main concern is certainly the need to fully explore my PM settings that could help me to control my arrhythmias that are triggering AF.  Premature Atrial contractions clearly initiate my Atrial Fibrillation as confirmed by my Intracardiac ECGs.  I don’t think there is too much more they can do to help with my settings in my current model of pacemaker, but any upgrade in the future should take into account my desire for better algoriths/features to manage Atrial Fibrillation since I am against more invasive treatments.

Your contribution has been invaluable.  A lot of what you say is obvious but often forgotten when we are suffering and feeling so vulnerable.   We need to be reminded of what we can do to help ourselves and your contribution sets out a clear plan that we can all understand and work with, so a big thank you

Pacing

by Aberdeen - 2023-08-12 11:16:15

Thank you Gemita for your reply. Fingers crossed -I have been feeling well since my lead replacement last April . Your comments are very informative and appreciated.

My experience

by Good Dog - 2023-08-12 13:59:18

I have had many different EP's in the almost 37 years I've had a PM. My experience has always been that my EP's seldom explain much, but have always been willing to answer questions or concerns that I have. My current EP at the Cleveland Clinic just left the practice to work in the private sector. He was the best that I've ever had in terms of explaining things and he had a way about him that made me feel comfortable and confident in his care. However, he is gone and I have yet to meet my new Doc that will likely perform lead extractions for me. He is very experienced and was highly regarded by my previous EP. So instead of focusing on my Doc's, I'll limit my response here to the PM Tech's and interrogations I've experienced over the years. 

In the 36+years that I have had a PM my experience has been that the PM Tech's I have seen generally assume that I know nothing about my PM. I don't want to generalize, because I know that others have had much different experiences. However, this has been my experience. They rarely explain anything about my PM and some seem hesitant to even answer questions. All of the Tech's almost always ask how I have been feeling and if I've had any issues. My response has always been "fine" and "no". They usually (I stress the word "usually") tell me when they are tinkering with it (performing a test) and that I may feel something for a moment or two. It took me a while to learn what they are actually doing in detail, because again, they seldom explain. I have found that I need to ask questions if there is anything I want to know. Based upon my experience it seems as though most people do not want or care to know much. I say that, because they often seemed surprised and/or even taken aback when I ask questions.

Since getting my PM at a relatively young age, I have always tried to live my life as though I do not have one. I have had very few problems over the years and so until recently (since having some issues), I had never allowed myself to focus on the fact that I have a PM. So if I feel normal, I have always assumed that all is well unless someone tells me otherwise. The last Doc that I had for over 20 years required an in-office PM interrogation after every other remote interrogation. The technicians usually had little to say and often the only question they asked was; "how have you been feeling"? So since I was generally always good, that was it. However, at my Doc of 20 years, the Tech's called me at home each night after every PM check. I am sure they were doing it for all the right reasons, but I hated that and I really came to dread those calls. As I had said, I tried not to think about the fact that I had a PM, but it seemed like they never allowed me to forget it. They didn't ever call to say that everything was O.K. which it always was. I suppose that they had to have a basis for the call, so they would often say that I had arrhythmias (that I was usually unaware of or accustomed to). They would say that they were either very brief and/or they were nothing to worry about (PVC's and other benign disturbances). Of course, that caused me to worry!  I always wanted to tell them; well if there is nothing wrong, then stop calling me. However, I just never did! 

I have found that in the smaller hospital systems with which I have been familiar, the Tech's generally cannot make any changes without the Doc's permission and/or knowledge. However, I am now (recently) being seen at the Cleveland Clinic which is a very big system. They have a separate department for PM Tech's that seem to have more latitude than what I had experienced in the past. Here, they can make what I consider to be significant changes, without consulting the Doc whenever they think it is necessary. So I assume that they must have a higher level of training, but I am not sure. I've found that giving them that much latitude may not always be a good thing. My first in-office interrogation at the Clinic was uneventful and it seemed that the Tech was very knowledgeable. He did not ask me anything or say much. I asked a bunch of questions that he briefly and politely answered. So that evening when I was walking my dogs I noticed my heart racing. My pulse was about 120 bpm which seemed very unusual and it was uncomfortable. It was very concerning when my heart was pounding rapidly for no apparent reason. So when I arrived back home, I checked the interrogation report from that visit earlier in the day. I could not believe my eyes when I read that the Tech had turned-on the rate response. In the 36 years I have had my PM it had never been turned on. I had occasionally been asked by the PM Tech's and my Doc's over the years if I wanted to try it, and I always said "NO". I discussed turning it on with my last couple of EP's and asked their opinion. They always agreed that unless I felt that I needed it, then it was best to just leave it off. On this occasion it wasn't that I had an issue with the fact that this particular Tech decided that I needed the rate response turned-on. No, it was simply that he did not ask, and more importantly; he never bothered to tell me he turned it on! I spoke with his supervisor and was simply told that this Tech was one of the best that they had. However, she did acknowledge that he should have told me. When I complained to him directly he acted very indignant. He said that he had 16 years of experience and nobody ever questioned his judgment. He didn't seem to get the fact that my problem was that after living with a PM for 36 years, he did not understand or seem to care that there may have been a reason it was never turned-on. Nor did he seem to understand that I would have expected him to inform me when making a significant change such as that.  

So that is my story in a nutshell. I think it is safe to say that in all my years of experience with my PM, life has been pretty uneventful in a good way. That is; until recently finding-out that I have PM syndrome and require lead extractions and a couple of new ones implanted. That is complicated somewhat by the fact that I still have one original lead in the atrium and a 29 year old lead in the ventricle. I do consider myself fortunate to have one of the best heart hospitals in the country very close to home.

Pacemaker clinic experience

by AgentX86 - 2023-08-12 22:49:13

I'd wrap my experience up into just a few words.  She (the same person since shortly after implant) basically tells me anything I want to know and discusses any findings.  She'll also show me how my pacemaker is set up and even asks if I want to try a different setting. 

A couple of weeks ago, I had a few Kardia EKGs and was asking her about them. She said the nasty looking ones were just noise but showed me some detail on the PVCs.  There is an additional pacing spike after the PVC that "paces through" the PVC.  Essentially, when it detects a PVC, it reponds immediately with a pacing pulse before resetting its timer for the next pace.   This "pacing through the PVC" preserves L/R synchrony during a PVC. I thought that was pretty cool.  She asked if I want to try it with that feature off.  I didn't think it would help any and it's certainly there for a reason.

Basically, she goes into the detail as deeply as I want to go.  I'm sure most don't want to know anything and I'm sure that's fine too.

Re: Puck staying on.  She hangs it around my neck so it rests on the PM.

Good Dog

by Gemita - 2023-08-13 04:32:29

As a member with a long pacemaker history, your contribution is invaluable, as always, so thank you.  

It has been my experience too, at least in the first few years of having a pacemaker, that very little “technically” was ever explained either by the EP or pacemaker technician when I attended clinic.  I have only got answers when I have dug deep and asked searching questions, but knowing “what to ask” when both my rhythm disturbances and pacemaker functions are so complex, was an exhausting study in itself.  In the early days, I often came away from my appointments disappointed with the outcome . . . and certainly none the wiser.  

I can imagine you have concerns now that your caring EP has left the practice and I hope you will find your new EP supportive and equally competent.  He certainly sounds capable with lead extractions/implants.  Good placement of the new leads and careful explant of the old ones, will certainly be important for your future wellbeing.   

I hope an upgrade will fix the pacemaker syndrome and improve your symptoms and any early signs of heart failure.  An upgrade should certainly restore optimal pacing and help improve ejection fraction, so I am keeping my fingers crossed for a good outcome for you.  You certainly deserve it.

I am sorry you had a problem with Rate Response. (Mine has been turned OFF too now).  I cannot understand why your technician suddenly decided it needed to go ON after all these years and then didn’t have the courtesy to tell you, or to explain what possible symptoms switching it ON might cause.  Like you are discovering out there, some technicians are clearly authorised to carry out settings changes without any input from the cardiologist/EP.  In my experience here in the UK, most technicians are able to carry out settings changes without any input from the consultant EP.  In my hospital, all technicians for example are highly qualified “cardiac scientists” and important members of the Cardiac team.

Good Dog I hope you will receive an upgrade soon and that your symptoms can effectively be treated so that you may continue to enjoy a quality of life. Please let us know when an upgrade is scheduled?  In the meantime, thank you again for contributing to my thread.

AgentX86

by Gemita - 2023-08-13 05:28:14

Hello AgentX86, it was good to receive your contribution.  I can see that you have had “continuity of care" since implant and that can make a real difference.  I like the fact that your technician involves you, even to the point of asking whether you would like to try another setting.  She obviously senses that you know about these things.

Thank you for explaining more about your Kardia Mobile EKGs and that the “nasty” looking areas were caused by noise, rather than by any serious rhythm disturbance.  I suppose that is reassuring although I know you are still symptomatic with your PVCs so the problem hasn't gone away.  Your technician certainly took time to explain in detail what was seen on your Kardia Mobile EKG strip.  Am impressed with the care you are receiving.

I will have another look at your Gallery EKG pic to see if I can work out what your technician was talking about although her comments make a good deal of sense.  I can appreciate that during slowing, pausing, irregular ectopic heart beats, it would seem wholly appropriate for the pacemaker to respond to these disturbances with an immediate pacing pulse before resetting its timer for the next pace.  I see that "pacing through the PVC" preserves L/R synchrony during a PVC.  I think this is a pretty cool feature too, but I am surprised it isn't helping more?

I see the technician gave you the option of having the feature switched OFF.  I am sure it is there for a reason too, but if your PVCs don’t improve despite the PVC feature being turned ON, mightn’t it be worth a try to have it switched OFF for a week or so to see what difference it might make?  Can’t do any harm I suppose for a brief period.  I would certainly consider it in the future if your PVCs cannot be controlled.

Gemita

by Good Dog - 2023-08-13 10:27:57

Gemita,

You said; "knowing “what to ask”  was an exhausting study in itself."

I just want to say that I owe a debt of graditude to this forum and more specifically to the many people that have contributed here over the years! This has been an invaluable resource in helping to educate me and provide a level of comfort that otherwise would not be available. At least to the extent that when problems developed and/or if there was something that I did not undertsand or needed to learn more about, this was often my only go-to and also often my first stop.

Thanks to you and all of those that are so generous with the time and willingness to help others!

knowing what to ask . . .

by Gemita - 2023-08-14 07:18:28

Good Dog, I echo your comments about the help I have received here too and you have been a valuable contributor, don’t forget that.  

Each one of us has an important role to play and we all learn from each other.  Answering questions and trying to break down the symptoms of suffering members, may help us to understand and to accept our own condition better too.  Many members have complex conditions and yet they bravely come here to help others or to post their success stories and it truly lifts my spirits.  It is a very special Club