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Jan 6, 2019

In this episode we will discuss Trigeminal Neuralgia with Pamela from British Columbia, Canada.  This painful and rare condition has no cure but Pam gives us tips on dealing with severe facial pain.


s3e1 trigeminal neuralgia.mp3


Lita [00:00:07] Hello and welcome to another episode of podcastDX. The show that brings you interviews with people just like you whose lives were forever changed by a medical diagnosis. I'm Lita and one of our co-hosts. Ron is not with us today.

Jean [00:00:22] And I'm Jean Marie.

Lita [00:00:23] Collectively we are the hosts of podcastDX on today's show we are speaking with Pamela. Pamela is joining us once again from Victoria British Columbia in Canada.

Jean [00:00:35] And we actually had the honor of speaking with Pamela last week regarding fibromyalgia this week. Pamela is here to tell us all about her experience with the trigeminal neuralgia.

Lita [00:00:45] Well ok that's a mouth full. (Laughter) In case you missed last week's episode Pamela is happily married to her amazing husband Ray and they're the proud parents of two grown kids with three wonderful grandsons. Pamela worked for years whilst battling with pain from fibromyalgia and osteo arthritis while employed as an administrative specialist. She was also a certified event planner with her career behind her now and she is on long term disability. She is now a blogger. I've always wanted to blog. I'm not into blogging but maybe you can get me going on it (laughter) she really, I need to know. She writes about chronic pain chronic fatigue fibromyalgia an invisible illness in addition to blogging. Pamela is an active volunteer with the patient volunteer network or PVN in British Columbia. Outside of the PVN she has also done volunteer work for Island health as a patient advisor. She was on the advisory committee for opioid guidelines in Canada and volunteered this summer with the downtown Victoria Business Association Buskers Festival.

Jean [00:01:56] Hello again Pamela and I, might I say that I'm just exhausted hearing about how much you do. Welcome back.

Lita [00:02:03] Yes.

Pamela [00:02:04] Thanks so much for having me back again.

Lita [00:02:07] Pamela I was reading over the data sheets for the conditions that have placed you on the long term disability list. And I would venture to say that you have your plate full. We have....

Pamela [00:02:18] I do.

Lita [00:02:19] ...(laughter).

Jean [00:02:20] Yeah.

Lita [00:02:21] ...Separated the two major conditions into the two separate episodes. We covered fibromyalgia last week and that leaves this week with trigeminal neuralgia. First to give our listeners an idea of exactly what we're talking about what is trigeminal neuralgia.

Pamela [00:02:37] Trigeminal neuralgia is a chronic pain condition it involves the areas inerverated by the 5th cranial nerve so the area of the body involved is the face it can cause severe pain even when doing simple things like brushing your teeth shaving putting on makeup touching your face eating drinking speaking or even when something as simple as a breeze whispers across the face.

Jean [00:03:04] Oh Pamela you mentioned the fifth cranial nerve and what is that exactly.

Pamela [00:03:12] OK so the fifth cranial nerve is one of the most widely distributed nerves in the head.

Jean [00:03:17] OK.

Pamela [00:03:17] So the classic type of trigeminal neuralgia disorder called Type 1 or TM1 causes extreme sporadic sudden burning or shock like pain which may last from a few seconds to as long as two minutes per episode.

Lita [00:03:32] mm mm.

Jean [00:03:33] oh God.

Pamela [00:03:33] And episodes can often come in a series of attacks that lasts for several hours.

Jean [00:03:38] ohh.

Pamela [00:03:38] But I have something called atypical TM.

Jean [00:03:41] ok.

Pamela [00:03:41] Which is when the pain comes in a long lasting wave...

Jean [00:03:44] ohhh.

Pamela [00:03:45] ...Instead of a short burst. So for me no but for me it's like a hundred little cameras there hitting the same area of my face...

Lita [00:03:52] Oh my gosh.

Pamela [00:03:53] ...For hour after hour.

Lita [00:03:54] oh my God.

Pamela [00:03:55]  my episodes tend to last for eight to 12 hours at a time.

Lita [00:04:00] Oh.

Pamela [00:04:00] They start just under my right cheekbone and then it spreads first to my sinus cavity then down towards my jaw. And I often feel spasms in my esophagus as well.

Jean [00:04:11] Oh my gosh.

Lita [00:04:12] Wow.

Pamela [00:04:14] Yeah.

Lita [00:04:14] Wow.

Pamela [00:04:15] Not fun.

Lita & Jean [00:04:15] No.

Jean [00:04:16] Wow.

Lita [00:04:17] Wow. I mean my mouth hurts just.

Pamela [00:04:20] yeah.

Lita [00:04:20] Listening to you.

Jean [00:04:21] That's that's awful.

Pamela [00:04:22] Mmhmmm

Lita [00:04:23] Pamela what causes Trigeminal neuralgia.

Jean [00:04:25] And how can we avoid it.

Lita [00:04:27] Yeah.

Pamela [00:04:27] Well there's actually several possible causes for trigeminal neuralgia. So it sometimes begins as the result of the nerve sheath being too close to a blood vessel in the neck area where it exits the brain stem.

Jean [00:04:42] ok.

Pamela [00:04:42] In other cases it can be caused by things like multiple sclerosis.

Lita [00:04:46] Which also takes away the sheath, right.

Pamela [00:04:48] Yeah exactly. Another reason for this condition can be a tumor pressing on the nerve or it might be the result of the wearing down of the sheath of the covering on the nerve. It could be the result of physical damage to the trigeminal nerve perhaps from the sinus surgery or an oral surgery or stroke or other facial trauma.

Jean [00:05:10] ok.


Pamela [00:05:10] In my case we suspect that the nerve is rubbing against something based on the MRI scan that I had done.

Jean [00:05:17] OK.

Lita [00:05:18] Wow can you tell us. I mean you know obviously the pain right. Is that what led you to to find out what this diagnosis would be.

Pamela [00:05:27] Yeah. The reason I was sought treatment was because I was suddenly having these pain episodes in my face. And after the first one or two I realized they weren't just sinus infections because I wasn't showing any other symptoms that you would typically get with an infection.

Lita [00:05:42] ok.

Pamela [00:05:43] So I saw my doctor and I described the pain. And I was diagnosed TM based on the description. And then when I was first put on medication it stopped the episodes from happening and that's when we knew that we'd made the right diagnosis.

Lita [00:05:56] OK. Is it just a nerve pain type of a medication then.

Pamela [00:06:01] Yeah. That's what we started with. One of the first drugs that they prescribed to. Yes.

Lita [00:06:06] OK. Well while reading about this week's topic I read that a person with trigeminal neuralgia might feel as if they had an abscess tooth or like you were saying a sinus infection. And since it can affect the jaw area it seems like that could make it a difficult condition to diagnose. I mean like is it a tooth is it.

Jean [00:06:27] Sinuses.

Lita [00:06:28] Sinuses. Is it Is it the gum you know. So was it it was not that difficult for you to get the diagnosis though huh.

Pamela [00:06:36] No like I said just describing the pains my doctor and how it flared into my sinuses first and then into my jaw helped him to realize that it wasn't an abscess in the jaw area.

Lita [00:06:48] Yeah actually you know what about a heart attack.

Jean [00:06:50] Yeah I'm you know yeah. You could have jaw pain.

Lita [00:06:52] You could have had jaw pain with a heart attack.

Jean [00:06:53] Sure.

Lita [00:06:54] There's a lot of things that.

Jean [00:06:55] Yeah.

Lita [00:06:56] They could have worried about.

Jean [00:06:57] well, yeah.

Lita [00:06:57] I'm glad the doctor thought about it right away.

Jean [00:06:59] you've had, Yeah. You had someone that really...

Pamela [00:07:01] Yeah.

Jean [00:07:01] ...understood what it was.

Lita [00:07:01] understood it right.

Jean [00:07:02] Yeah. And I understand that there are several tests that can be done to help determine the extent of the terminal neuralgia. Can you tell us a little bit more about this testing.

Pamela [00:07:11] Yeah. So in most cases the doctors start by asking questions about your symptoms and ask about your medical history. Then they usually perform a physical examination of the head in the neck areas including the ears the mouth the teeth and the temporal mandibular joint with the TMJ.

Jean [00:07:31] Right.

Pamela [00:07:31] And other disorders that may cause facial pain and mimic TM type pain. They'll ask questions about that. So these conditions need to be ruled out first before a definitive diagnosis was made. And then often what they'll do is they'll order a magnetic resonance imaging an MRI scan.

Jean [00:07:53] Ok.

Pamela [00:07:53] They do that to rule out the presence of a brain tumor or multiple sclerosis or other causes.

Jean [00:08:00] ok.

Pamela [00:08:00] And the scans can also determine whether or not a blood vessel is pressing on the nerves. And so that's what my doctor did was he ordered the MRI for me and that's where we could see how the nerve was being compressed.

Lita [00:08:12] OK. Wow that's quite a few tests. I know that when we were talking last week you said that during a procedure.

Jean [00:08:21] Something was leaning on a nerve.

Lita [00:08:22] Something was leaning on a nerve. Now could that have caused this.

Pamela [00:08:26] Yeah. Oh yeah. They they could see that the blood vessel is pressing against the nerve.

Jean [00:08:34] OK.

Lita [00:08:34] So it wasn't something that the doctor was leaning against. It's right now it's just a blood vessel. That’s pressing because I'm just saying like what made what made the blood vessel all of a sudden press against the nerve.

Pamela [00:08:44] You see they're not really sure.

Lita [00:08:46] OK .

Pamela [00:08:47] They're not really sure what's what's causing it to do that. And actually until I undergo you know some type of surgery they wouldn't be able to say for certain until that happens.

Lita [00:08:59] ok When I don't know if I asked when did this problem start compared to the fibromyalgia.

Pamela [00:09:05] I've had the TM for probably about 14 years now.

Jean [00:09:10] oh my gosh.

Pamela [00:09:10] And I didn't realize that I had it in the beginning simply because I thought it was a sinus infection.

Lita [00:09:18] OK.

Pamela [00:09:19] When I first had it and the episodes were really infrequent in the beginning so I just brushed it off. So when I started having them on a much more frequent basis then I knew that there was a problem. And that's when I went to the doctor.

Lita [00:09:33] got it.

Pamela [00:09:33] So I would say 14 years in total. But you know on a more frequent basis probably over the last four years.

Lita [00:09:41] OK.

Jean [00:09:42] ok And  Pamela you said that some medica.. Medications have helped a bit. Are there any other treatments available for patients with trigeminal neuralgia.

Pamela [00:09:50] Yeah. There are treatments for trigeminal neuralgia which can help to reduce pain and improve quality of life. So what they normally do is they start off with a medication called carbamazepine which is also known as Tegretol. That's the first drug of choice. And if that doesn't work or if it stops working as it did in my case the other drugs that they use are called lamatrine gabapentin and pregablin and then sometimes use Baclofen which is a muscle relaxant. And then I also took a drug called topiramate.

Lita [00:10:26] topiramate.

Pamela [00:10:26] which I don't take right now.

Lita [00:10:28] Yeah.

Pamela [00:10:28] Yeah. It's an anticonvulsant and that worked for me for a long time actually for almost two years. But it has stopped working and I am now at a point where I am having flare ups about once a week.

Lita & Jean [00:10:44] ohh.

Pamela [00:10:44] So yeah. And so at this point unfortunately I have no other drug options left. I even tried botox botox is often used as a last resort where they inject botox along the hairline not into the actual area where you have the infection but they do it along the hairline and that's done to try and paralyze the muscles that are flaring up from, from the nerve. But that was unsuccessful for me as well. So now the only option left for me is a surgical option.

Jean [00:11:17] Oh wow that's Yeah. You can't go back to a medication like if you're on a medication for sometime and it stops working.

Pamela [00:11:24] There's. Yeah. There is once medication stopped working that stops working and you can't go back to the old again. They just. They just don't work again.

Jean [00:11:35] Okay. Okay. And Pamela I really think we should let our listeners know that this is a disorder which is considered to be one of the most painful human conditions.

Lita [00:11:45] Yes.

Jean [00:11:46] And just reading that statement makes me really cringe. In your opinion how bad would you say the pain is.

Pamela [00:11:54] Well the nickname of this condition is the suicide disease. When I'm in a full TM flare up I'll be honest I want to claw my face off. The pain is a 15 out of 10. It is absolutely unrelenting. And that's the worst of it. If I knew I was going to get relief in just a short period of time it would be easier to bear. But when I get the telltale pulse under my cheekbone that a flare is coming up. I know that I'm in for 12 hours of agony. It's the most painful thing that I have ever experienced.

Jean [00:12:30] I'm so sorry.

Lita [00:12:31] Oh goodness gracious.

Jean [00:12:33] Yeah that’s.

Lita [00:12:33] Pam. And too bad they can't have like. I know that this...

Pamela [00:12:37] There's.

Lita [00:12:37] ...sounds bad, like put you to sleep. You know like put you in a semi coma. Knock you, you know go in for a shot. You know like you you go in for this.

Jean [00:12:44] Imitrex.

Lita [00:12:46] no not Imitrex to get the sleep that I went in for the shots.

Jean [00:12:49] Oh yeah.

Pamela [00:12:49] Yeah there's times that I've I've debated going into the emergency room to see if there's anything that they can do to help me.

Jean [00:12:58] Right.

Pamela [00:12:58] And I've gone once or twice and I've said to them I am in the middle of a TM flare up and I just want something to break the cycle of pain.

Lita [00:13:07] yeah.

Jean [00:13:07] Right

Pamela [00:13:07] . And even when they've given me something it hasn't always worked.

Lita [00:13:13] The Twilight that's what I'm thinking.

Jean [00:13:15]  the twilight sleep yeah.

Lita [00:13:16] The twilight You know like when they put you out temporarily while they're doing your procedure.

Jean [00:13:21] right.

Lita [00:13:21] I wonder if. Have you tried it would that break it. I know, you know they have that done the dentist's office.

Pamela [00:13:26] No They won't actually do something like that. But that's what they'll do is they'll give me a shot. I'm allergic to morphine.

Lita [00:13:33] am I.

Pamela [00:13:34] The best that they'll do is they'll give me a shot of fentanyl.

Lita [00:13:36] . Right.

Pamela [00:13:37] But even Fentanyl doesn't...

Lita [00:13:38] doesn't touch.

Pamela [00:13:40] ...touch the pain.

Lita [00:13:40] Doesn't touch it.

Pamela [00:13:41] No.

Jean [00:13:41] Wow.

Pamela [00:13:42] Well I know that I'm going to. And actually I have to be honest with you as we're talking I can feel a tiny pulse in my cheekbone that there's going to be flare ups coming up at some point.

Jean [00:13:53] I'm so sorry.

Pamela [00:13:53]  in probably the next few hours. (laughter)

Lita [00:13:56] Oh man. Does meditation. Does that help.

Pamela [00:14:00] Nothing.

Jean [00:14:00] It sounds like it's like asking someone who is in labor. "Oh have you tried this medication".

Lita [00:14:03] No no. I'm thinking before it happens.

Pamela [00:14:04] No

Lita [00:14:05] I'm just thinking.

Jean [00:14:06] Oh.

Lita [00:14:06] I'm thinking before it happens.

Jean [00:14:06] ok ok. 

Pamela [00:14:07] nope.

Lita [00:14:07] yeah. I mean yeah I remember when I was first pregnant with this one over here. Right.

Jean [00:14:12] Yeah. I don't remember.

Lita [00:14:14] No she doesn't remember it but I remember this. And I do have Alzheimer's and I don't remember a lot of things but I remember that when I was in labor my husband at the time pulled out a deck of cards and said "Would you like to play cards."

Jean [00:14:27] You know what's really funny. I remember when my sister was in labor and her husband pulled out a deck of cards.

Lita [00:14:33] What is with these guys.

Jean [00:14:34] I don't know but.

Pamela [00:14:35] I don't even know. (laughter).

Lita [00:14:36] Oh yeah. I mean who the heck wants to play cards when you're in that much pain.

Pamela [00:14:42] It's not really a distraction is it.

Lita [00:14:44] No it's not. I wanted to take that deck of cards and.

Jean [00:14:48] OK.

Lita [00:14:49] ok.

Jean [00:14:49] and back to the show.

Pamela [00:14:49] Put the cards there (laughter)

Lita [00:14:55] (laughter) Well how has this particular disorder affected your family or friends or your interactions with them.

Pamela [00:15:01] Well when I'm in the flare I can't do anything. I can't Talk. I can't be around anyone.

Lita [00:15:06] sure.

Pamela [00:15:06] Everyone. I mean I'm just writhing in pain. I don't want to be touched or talked to. So any contact with my husband is out and he's he's really good. He's really understanding about this. And you know he just makes himself scarce and I just go to the bedroom in the dark and just cry.

Lita [00:15:23] So it's kind of like a migraine.

Jean [00:15:24] It is yeah

Lita [00:15:25] Yeah a little bit but then.

Pamela [00:15:26] Yeah I just.

Lita [00:15:27] But different Yeah.

Pamela [00:15:28] I want to isolate myself.

Lita [00:15:29] Right.

Jean [00:15:29] Sure

Pamela [00:15:30] I just want to isolate myself my attacks are becoming so more frequent that it really interferes with my life.

Lita [00:15:36] Sure.

Pamela [00:15:36] I mean you know I don't want to socialize I don't want to be around anyone.

Lita [00:15:41] cause You don't know if it's going to happen when you're out.

Pamela [00:15:42] I don't want to do anything....

Jean [00:15:43] Right.

Pamela [00:15:44] Well and that's the other thing I never know when a flare is going to happen. I don't know if it's going to happen when I'm out and if I am out I just want to get home as quickly as possible so it's ruined a lot of plans....

Lita [00:15:56] Right. Right

Pamela [00:15:57] well.

Jean [00:15:57] Sorry.

Lita [00:15:58] Well I hope the. I hope the surgery option will work for you.

Pamela [00:16:03] Well I'm crossing my fingers. I do have an appointment with the neurosurgeon in April so.

Jean [00:16:09] oh ok good.

Pamela [00:16:09] I think well we'll talk about that in a few months.

Lita [00:16:11] Yes we will. Yes. We'll have to get you back out here in May.

Jean [00:16:14]  right.

Lita [00:16:14] We'll be praying for you in the meantime.

Jean [00:16:16] Yes. Are there any specific support groups for patients with terminal neurologic it sounds like.

Lita [00:16:22] They should.

Jean [00:16:23] The only person that can truly understand this is someone else that has the same condition.

Lita [00:16:27] Yes.

Pamela [00:16:28] Yes there are support groups available and you can certainly look online to find one suitable for you.

Jean [00:16:35] ok.

Pamela [00:16:35] In the States there's the American Association of neuromuscular and electro diagnostic medicine which offers information and assistance.

Lita [00:16:44] I'll put that on the web site.

Pamela [00:16:44] And they can be found, yep, It'll be on the website. They can be found at AANEM dot org.

Lita [00:16:50] OK.

Jean [00:16:50] OK.

Pamela [00:16:51] And in Canada there's the tri geminal neuralgia Association of Canada. They're known as TNAC and they can be found at T N A C dot org...

Lita [00:17:02] OK I will put it on our website. Yeah I didn't know if I told you but....

Pamela [00:17:06] ... but those are.

Lita [00:17:06]  yeah. We. We build web pages for you and for your particular diagnosis. on our Web site.

Pamela [00:17:13] oh that's wonderful.

Lita [00:17:13] So that'll be on there forever.

Pamela [00:17:15] so people can find that information.

Lita [00:17:16] Yeah.

Pamela [00:17:16] That's great.

Lita [00:17:17] We put links in resources so that people can have a one shop stop to find out more about it.

Pamela [00:17:23] Yeah. That's wonderful because I mean people you know the support is just immense that you know you can connect with people who are going through the same thing and like you said nobody knows what it's like except somebody who experiences it . And so you know I think it's really important that people know that there are national associations available out there for us.

Lita [00:17:46] That's good. And how about on Facebook. Are there those private groups.

Pamela [00:17:50] I am not sure about Facebook, there's probably lots.

Lita [00:17:54] ok.

Pamela [00:17:54] Of private groups that you can look for on Facebook.

Lita [00:17:56] OK. Because I know that I join a bunch of them just so that I can glean information so that I can have a little bit better idea when I'm talking to our guest and I can read all kinds of you know interactions between patients that have these different issues and you know I had this or yes we have that and oh my god do you remember when this oh yeah yeah.

Jean [00:18:15] and have you tried this.

Lita [00:18:17] Yes. And all kinds of handsome tips. I love those.

Jean [00:18:20] right.

Lita [00:18:20] Well yeah obviously we found out that this problem does not go away on its own and it can get worse over time. And you are looking for possible surgery as a cure in the future.

Pamela [00:18:35] That's right.

Lita [00:18:36] Have you have you been told to watch for any other symptoms or is it just an increase in the severity.

Pamela [00:18:42] It's really just an increase in the severity and the frequency that I have the flare ups and stuff.

Lita [00:18:48] OK.

Pamela [00:18:49] Some people do achieve remission. Some people have flare ups that go away.

Lita [00:18:54] Oh good.

Pamela [00:18:55] And they achieve remission so that there is encouraging news. Some people like myself run out of options and need to look for treatments beyond medication.

Lita [00:19:04] OK.

Jean [00:19:05] OK. And as we had mentioned earlier that there may be surgical procedures to help alleviate some of the pain caused by trigeminal neuralgia. And like you said your schedule coming up.

Lita [00:19:18] in April Right.

Jean [00:19:18] And that's umm.

Pamela [00:19:20] That's right.

Pamela [00:19:20] So I have an appointment on April 30th to see a neurosurgeon and we're going to be talking about a brain surgery called Microvascular decompression.

Lita & Jean [00:19:30] OK.

Pamela [00:19:30] So what that means is the surgeon will make a circular incision behind my right ear and remove that part of my scalp and then using small tools. He'll find the trigeminal nerve and then place a small Teflon sponge between the nerve and whatever.

Lita & Jean [00:19:46] Oh wow.

Pamela [00:19:47] Is pressing which is probably another nerve or you know a tendon or whatever is in there but whatever's causing the irritation he'll place the Teflon sponge between the two.

Jean [00:20:01] Ok.

Pamela [00:20:01] And once that's done the bone that was cut away will be. Covered with a titanium plate instead. And then the muscles in the skin are all sewn up again and I'll spend one night in the ICU. And then one or two nights in the hospital and then home to recover.

Lita [00:20:17] Ok

Pamela [00:20:17] So there's an excellent success rate with this particular surgery. And the reason I've chosen this surgery is because it has the lowest rate of causing facial numbness as well. There are other surgeries including one called the sensory rhizotomy which is the irreversible cutting of the trigeminal nerve root at its connection to the brain stem.

Jean [00:20:41] Ok.

Pamela [00:20:41] There's Gamma Knife radio surgery which is a non-invasive outpatient procedure that uses highly focused radiation beams and it destroys some of the trigeminal nerve root fibres that produce pain and then there's peripheral peripheral neurectomy which is where a nerve branch is cut.

Lita [00:20:59] Well you got to become a.

Pamela [00:21:00] . Yeah right.

Lita [00:21:01] You're becoming quite good with the medical terminology.

Pamela [00:21:04] I really am I.

Lita [00:21:05] (laughter)

Pamela [00:21:06] But all three of those surgeries carries a side effect of facial numbness and some to a really high degree. And I don't want that as a side effect.

Jean [00:21:16] Sure.

Pamela [00:21:18] I researched all four of these different surgeries very carefully and that's just not a side effect that I'm willing to put up with.

Lita [00:21:27] Sure sure.

Jean [00:21:28] Sure. Yeah.

Lita [00:21:29] Well we're not. When your husband wants to give you a kiss you'd like to know if he's close.

Pamela [00:21:34] Well exactly. You know and it sounds kind of funny to say it but there's a lot to be said for that sensation of touch.

Lita [00:21:42] Right.

Jean [00:21:42] Of course

Pamela [00:21:42] I'm not willing to give that up.

Lita [00:21:44] Absolutely. Absolutely. Do you have any additional tips hints or helpful advice for listeners.

Pamela [00:21:50] Well my main advice is just to see your doctor as soon as possible if you're experiencing any type of facial pain. The sooner you get it diagnose the better. And if it is trigeminal neuralgia there's help available. Find a good support group. Facebook has groups available to help. And most importantly just know that you're not alone. There are lots of other people out there who are suffering so you know don't feel that you're the only one that's out there.

Jean [00:22:18] Well thank you Pamela. And how can our listeners learn more about you and trigeminal neuralgia.

Pamela [00:22:26] I blog at Pamela Justin dot com and I have a few posts about my TM. So just do a search on my Web site to find them and hopefully you'll get some help from reading those posts.

Lita [00:22:37] OK. And we'll put a link at our Web site so that they can find you. Well thank you Pamela...

Pamela [00:22:42] absolutely.

Lita [00:22:42] ...Once again for joining us. This has been wonderful.

Pamela [00:22:44] Oh it was a delight to be here again. Thank you so much for having me.

Lita [00:22:48] You're welcome. And we will be contacting you again in May to find out the rest of the story.

Jean [00:22:53] Yeah see how everything in April went.

Pamela [00:22:54]  Wonderful I'll certainly be happy to let you know what the surgeon has to say.

Lita [00:22:59] Great.

Jean [00:22:59] great.

Lita [00:22:59] . And for our listeners if you have any questions or comments related to today's show you can contact us at podcast D X at yahoo dot com through our Web site podcast D X dot com on Facebook Twitter Pinterest or Instagram.

Jean [00:23:15] And if you like today's episode tell a friend as always please keep in mind that this podcast is not intended to be a substitute for professional medical advice diagnosis or treatment. Always seek the advice of your physician or other qualified health care provider with any questions you may have regarding a medical condition or treatment and before undertaking a new health care regime never disregard professional medical advice or delay in seeking because of something you have heard on this podcast.

Lita [00:23:41] Until next week.