Welcome from the Interest Section Chair
By Petra Davidson, R. EEG/EP T., FASET, BS
Greetings Fellow ASET member,
Happy Spring! Hopefully, you are enjoying spring wherever you reside. We are not yet there in Minnesota. Currently, nearly 18 inches of snow coat my yard. Tiny bunny tracks dotted across the glittery, diamond like snow suggest that spring is in fact on its way.
Recently, I changed employment. After 20 years as a clinical technologist, I am now a remote technologist. Everything I do resides behind a computer screen and headset. As I reconfigure my elevator speech to fit my new role, I called on our Special Interest Section Leaders to do the same. There are a few surprises in the articles that follow. I hope that you enjoy them as much as I did.
It is always intriguing to me to hear how others in the field describe what we do. I ask that you read these carefully and let us know what you find interesting or how you might change things to fit your unique role. That is the beauty of our field, each of us has a unique position! Happy reading!
Acute/Critical Care Neurodiagnostics
By A. Todd Ham, R. EEG T., CLTM, BS
For this section, I’ve prepared an “All Things EEG, 2nd Edition” crossword puzzle for you to exercise your brain muscles. To view the crossword puzzle, click here.
By Jennifer Carlile, R. EEG T.
Because I wear a few hats in my position, here is how I describe my job is: First, I always start with how much I love what I do. I’ve been in the Neurodiagnostic field for almost 30 years and I help Neurologists make a diagnosis for their patients who might have epilepsy. The other way I describe my job is: I offer a service to physicians, helping them determine whether their patients have epilepsy, seizures, or brain injury. I have been able to say for the past 29+ years that I love what I do and still love this field. How many people can honestly say that? I have been so blessed. In the beginning of my career journey, I started working in a major hospital system that saw the worst-case scenarios of brain-related issues, followed by selling equipment that helps detect brain-related issues, and now, full circle, I have the best of both worlds, offering an amazing service to these physicians and taking care of their patients. Love, love, love, love in honor of Valentine’s Day. Sounds sappy, but it is the truth! #blessed#lucky!
By Emily Scanlan, R. EEG T., BS
When asked about what I do, I try and relate it in terms that are appropriate to my audience. If I am talking to another healthcare professional, I will tell them that I monitor brainwaves of patients and look for any seizure-like activity or any abnormalities. Now, if I am talking to a non-healthcare person, I try and make my description fit their intellectual capabilities. My dad was a professor at the University of Minnesota and likes to know the little details of my job, so I will go into more details including why I may see certain things and how it may impact a patient’s prognosis. On the other hand, if I am talking to my sons (mind you, they have helped me as subjects for marking with my students), I go really high-level and say that I am monitoring their brain to see if anything is wrong. There is no need to go into detail as they won’t get it, which will, more than likely, just confuse them.
By Vicki Sexton, R. EEG/EP T., R.NCS.T., CNCT, CLTM, BS
My 5-second elevator speech to my patients who do not speak English and who have no one to translate, or a patient who is developmentally delayed is to say what I am going to do and act out what I am saying at the same time. As I explain what I am going to do, I do part of it on myself, then I show them either on their head (with marker and tape measure), or I show them on their hand. I will mark their hand, then rub with the prep, then apply an electrode so they know how it feels before I apply it their head. As I perform the test, I act out what I want the patient to do while speaking English. They usually start to understand as I repeat common commands, such as open eyes and close eyes. With the hyperventilation, I usually do it along with the patient, so they understand.
Taking the little extra time to explain, while acting out the steps usually gives a thorough study and calms the patient at the same time.
By Stephanie Jordan, R. EEG/EP T., CNIM, CLTM
One thing I certainly enjoy teaching the NDT students at our lab is how to communicate with our patients and put them at ease for their procedure no matter the challenge. We are fortunate here to have a diverse patient population with different ages, cultures, and ability to comprehend. For many, it is their first EEG and the patient arrives to the lab apprehensive and uncertainty.
First things first is to make the patient comfortable in their physical surroundings then explain what the EEG is. I avoid calling it a test because so many are apprehensive about “taking tests”. I tell the patient that the EEG is a recording of their brain cell activity in waveform, recorded by electrodes pasted onto the scalp. At this point I show them the electrodes and how they lay flat on the scalp by pasting an electrode on my hand. Speaking slowly and allowing time for the patient to ask questions as they occur helps to relax them. It is helpful to let the patient know that the test is non-invasive by telling them “I am not putting anything into or out of your brain, just recording the activity that naturally occurs there.” For young children, a simpler way is to say, “I am going to put these golden buttons on your head and take pictures of your brainwaves.” Children know they need to stay still for pictures and most enjoy it, so this is a good strategy. For all patients showing the entire bunch of electrodes and letting them know you will measure and mark with a crayon for each one gives them an idea of how the set up will go. Show the measuring tape and marker to the patient and let them know when you are going to touch their head. After the marking, let them know you are going to clean each spot and paste the electrode on there (show the cotton swab and cleanser). Letting the patient know that everything washes off with water when done can also put them at ease. For older patients who are familiar with EKGs, letting them know that the EEG is for recording brain activity like the EKG is for recording heart activity gives them a familiar comfort. For my 5-second elevator speech – my job is to get the best brain cell recordings for each patient I serve.
By Patricia Lordeon, R. EEG T., FASET
We frequently hear about and discuss how important communication is within our work space, but even then most of us don’t really communicate well. For example, we lament when a new policy is implemented, and we feel that insufficient information has been communicated to us about the change. We assume that our coworkers know what we mean without us having to actually utter the words. We think that everyone knew about that “something” being changed and are surprised to realize that some individuals were unaware (you mean the grapevine let us down??). And work issues are only the tip of the iceberg of communications. Don’t even get me started on communication in politics!
When you are trying to communicate with someone and there is a language barrier, the stakes are increased exponentially. At our hospital, we are fortunate to have the “blue phone”. It is a device that has two hand sets and plugs into a jack on the side of our existing hospital phone. Via the magic of technology, we can choose from a large variety of languages and dialects, and have a real-time, three-way conversation between tech, patient and translator. The company maintains a staff of translators available to speak with and translate for healthcare professionals. This luxury is obviously not available for every hospital and clinic setting, and we are blessed to have this advantage when working with non-English speaking patients. If you have to make do without this marvel of modern technology, you can prepare for these situations in advance by making a picture book of the application process. YouTube is another great resource, and of course, Google Translator makes everyone an instant linguist.
When I was a young tech, none of this technology existed (gives you a hint of how old I am). So, we had nothing to use or help us when working with patients who did not speak our language. Pantomime and picture drawing were our only resources when faced with this situation. It was far from optimal, and we have come a long way from those days. Obviously, communicating with non-English speaking patients and families is not an issue for us in our current work environment.
Back in those days, we were sometimes fortunate enough to test patients who had some small understanding of English, or even better, we had some small understanding of their native language. One day, long ago, I had the pleasure of working with a four-year-old patient and her mother who were at our facility for long-term video EEG monitoring. The patient and her mother spoke French exclusively. I was thrilled to be able to use my four years of high school French to help comfort them and assist in achieving good quality testing. I quickly realized that my school-taught French was no match for a native French speaking parent. I was able to communicate much better with the four-year-old patient (which told me that four years of high school French puts you on par with the conversational level of a four-year-old, French speaking child).
Despite our language barrier, we soldiered on with the testing. We made due with a smattering of French (on my part), lots of head nodding and pantomime, and some diagram drawing. This patient continued to travel to our hospital for the next twelve years, and we forged a strong bond during that time. The fact that the patient took an English class at home in her grade and high schools helped tremendously in our being able to communicate over the years. Her English was excellent, while I am sad to confess my French never really progressed beyond the four-year-old level I started with.
For me, determination and good humor were the two most influential factors in establishing a communication process with this patient. While there are certainly easier methods available now, nothing can replace the shared trial-and-error that made us laugh and smile and learn together. This family never forgot how, during the patient’s first-ever video EEG, I asked, in all seriousness, to “Ferme tes oeufs” (Close your eggs) instead of the intended “Ferme tes yeux” (Close your eyes). And I will tell you that I never, ever had the opportunity to use the only French phrase I recall from those four years of French class. “Ou est la piscine?” (Where is the pool?) is not something I have ever needed to ask when obtaining a medical history.
By Susan Hollar, R. EEG T., BA
There are many approaches to describing what an EEG technologist does each day. Of course, you should tailor your description based on your audience. Children tend to be very literal in their interpretation of what adults say. I have encountered more than one child, including my own grandson, who thought we sucked out the brains of children with our electrodes! There have been many who believed we could tell what they were thinking. I, personally, am glad that is not the case! My explanation has evolved as I have witnessed what seemed to work and what fell totally flat.
My typical, quick explanation for what an EEG tech does is: We make a recording of how your brain is working. We do that by placing recording wires called electrodes on your head (scalp). My main job is to make sure the recording is free from artifact or noise. We will have you do some activities to help the Neurologist see how your brain works. Those activities will include some special breathing, opening and closing of your eyes, and a special flashing light. All of this helps us see how your brain works.
I also really like the explanation (when appropriate) that it is like looking for a bolt of lightning or listening for thunder to see if there is likely to be a storm coming in the future.
It is also important to ask what the patient knows about EEG and then build on their knowledge.
Intraoperative Neurophysiological Monitoring
By Jeffrey R. Balzer, Ph.D., FASNM, D.ABNM
“So, What Is It You Do for a Living?”
In 26 years of performing IONM, if I had a quarter for every time someone asked me “what do you do at work?” I could have retired 10 years ago. Unlike other professions where people say, “I’m a pharmacist” or “I’m a mechanic” we typically answer, “I am a neurophysiology technologist” or a “surgical neurophysiologist” and that’s where people stop and look at us like we are speaking a different language. It is at this point that we often default to saying “oh, I work in the operating room” in an attempt not to go into detail of what we do. What we fail to realize is that we are missing the perfect opportunity to create and deliver a succinct layman’s explanation of what IONM is and what role we play in the care of our patients. Our answer should be almost reflexive and polished so that we can clearly convey what we do and how we generally perform IONM.
Typically answers begin with “I monitor the spine and brain during surgery in the operating room.” Family members then say, “so you are a surgeon”? Our answers concerning what we do should attempt to be more detailed while maintaining a level of basic verbiage. I begin by explaining that most, if not all surgical procedures, pose some level of risk. I then, for example, talk about the ideal situation for detecting complications during surgery. I tell people that if every spine or brain surgery could be done awake to allow for a continuous assessment of neurological function, we would do it that way. The confounding factor is that our patients are under general anesthesia, so a traditional neurological examination is impossible to perform. As such, we use specific tools that reflect an awake neurological examination and reliably provide information to the surgical team so that interventions might occur, thereby potentially preventing or lessening complications.
The next thing to describe are the tools we use and how we perform IONM. Depending on where and what the surgery is, I say we use tools to stimulate the nervous system and record activity that is generated. I often attempt to use analogies that most people understand to describe what we do. A basic description involving electricity and wiring is often very useful in these instances. I tell folks that what we do is analogous to us generating an electrical signal that travels along a wire. We continuously watch the signal moving along the wire measured at different points. If the wire (the spinal cord being the wire, for example) is interrupted, then we know when and where the problem occurred along the length of the wire. Once we detect an interruption, we immediately inform the surgical team who, in turn, investigates the potential cause. This typically gets the message across particularly for cases involving spine monitoring. As IONM become more complex our explanations need to be a bit more complex as well, and using these types of analogies is often very useful.
We should be using the opportunity with friends and family to polish our explanation of IONM testing so that we can utilize the explanation with patients and patient’s families when we are explaining the details of IONM to them or more importantly, acquiring an informed consent. The explanation needs more detail but still be succinct and accurate as patients and their families are often under far more stress than a family member who is casually asking what we do in the operating room.
One of the major components of informed consent is that information is given about a treatment or test so that the patient can decide if they wish to undergo a treatment or test. This process of understanding the risks and benefits of treatment is known as informed consent. The key component is that the patient must understand the relevant information. Decision-making capacity is also referred to as competency. Competency may be the most important components of informed consent. There are several different components of decision-making capacity:
- Ability to understand options
- Ability to understand consequences of choosing the options
- Ability to evaluate costs and benefits of consequences and relate them to personal values and priorities
The key to decision-making capacity or competency is predicated on the patient understanding the IONM, the risks and the options. We therefore need to ensure that our patients understand exactly why we are there and what we are going to do.
The explanation during informed consent should be more formalized, but nonetheless, basic enough for the patient to understand. If need be, similar analogies to those described above are perfectly fine to use conversationally. As for the written IONM consent, the following is an excerpt from a typical IONM consent form:
“Intraoperative neurophysiological monitoring is performed during a variety of surgical procedures to measure the function of the brain, brainstem, cranial nerves, spinal cord, spinal nerve roots and peripheral nerves depending on the type(s) of testing performed and the surgery. Electrophysiological measurements provide information to the surgeon in the operating room that may assist in identifying neural structures, aid in performing the surgical procedure itself and in detecting and preventing injury to the nervous system.
Central and peripheral nervous system function is measured using electroencephalography (EEG, an electrical map of the brain), electromyography (EMG, measurement of electrical energy to the muscles) and/or evoked potentials (EP, stimulated electrical activity) recordings. The surgical procedure and the parts of the nervous system at risk will determine which of these tests will be monitored. In some cases, these will be recorded simultaneously.
After the induction of general anesthesia but before the start of surgery, small, sterile subdermal (under the skin) needle electrodes will be placed and used as stimulating and recording devices. Baseline recordings will be made so that differences during the surgical procedure can be detected. Once the surgery has begun, recordings will be monitored continuously or near-continuously throughout the procedure and any significant changes will be reported to the surgical team. The information will be interpreted by a board-certified Neurophysiologist and recommendations will be made. Prior to you awakening from anesthesia, all the electrodes will be removed.”
Once an explanation, such as the one above has been given, the patient should be given a detailed description of what the potential morbidities are as they relate to performing IONM. In addition to the potential morbidities, quoting incidence as a percent is important. This can be based on the literature or on personal institutional experience. Some examples of these include the following:
- Infection. Infection may occur at the site of electrode application in the skin (estimated risk <0.1%).
- Burns. Burns at electrode site caused using electrical equipment such as cautery or by a malfunction of the neurophysiological monitoring equipment (estimated risk <0.1%).
- Hematoma. Because a needle is placed beneath the skin, blood may collect to form a hematoma (bruise or blood clot) (estimated risk <0.1%).
It is important that this list be complete and describe all possible instances in a succinct and understandable manner. This is all part of a complete description of IONM that needs to be provided to the patient and their families prior to the procedure.
Regardless of who we are explaining IONM to, whether family, friends or patients, we need to take great care to provide accurate and succinct information. Perhaps most important, particularly with patients and their families, we must make sure they understand the information and details because without this fundamental understanding, a legitimate decision cannot be made about the IONM.
Nerve Conduction Studies
By Jerry Morris, MS, R.NCS.T., CNCT, FASET
Hey, everyone! I hope everyone had a wonderful holiday season. I know I did. January and February are usually the dreariest months around Louisiana. Usually by March things start to brighten up and spring is around the corner. It’s still a good time to be inside, and my northern and eastern friends have so many colder and drearier days and nights ahead.
Having said that, I am writing this article during my fourth week of rehabbing from right knee replacement surgery. I finally bit the bullet and had it surgically repaired the second week of January. The surgery went great; only two nights in the hospital in a room right down the hall from my EMG lab. Great nurses, therapists, the works… They had me up and walking on a walker less than 24-hours post-op and with very little pain. NOTE: I got rid of the walker and the cane 6-days post-op. Debby, my wife, said I was showing off. The only drawback was that they ran bags of D5W continuously for two days. I have never gone to the bathroom that much in my entire life! Fluids were going in my arm and seemingly going right through me. I think I slept in 30-minute shifts during those two days. Discontinuing the IV was a significant highlight of my stay, but it did feel humbling to see the patient care and staff interaction from the other side of the fence. Once I got home, I began going to physical therapy (PT) two days later. For what it’s worth, the surgery was a piece of cake compared to the PT. For an hour, two to three days a week, I got pushed and shoved and flexed and extended until I was ringing wet with sweat. One of the patients who was there at the same time called them “physical terrorists”. They said it, not me! Then I got to do the same thing at home on my off days. By the time you read this I should be back at work, either on light duty or full time. Four to six weeks off is pretty normal for this type of surgery. Debby is being a jewel at taking care of me since it was my right knee I cannot drive until I get clearance, she has become my chauffeur. Being stuck at the house has given me time to work on projects for ASET and AANEM, as well as the “Honey Do” lists Debby writes out for me each morning! I miss my patients, doing clinical work, and the day-to-day routine, but keeping busy at home has eased my boredom. If I get tired of my computer work, I just turn on the sports talk shows for a while. I could really get used to this, but I still want to get back to my work routine. Can’t change 43 years of working habits in only three to four weeks…
For this article, I have been asked to give a quick explanation of what I do when I do nerve conduction studies and how I go about that explanation. I can probably safely say that NCS/EMG can be, and probably are, the most painful modalities of neurodiagnostic technologies, with the possible exception of SSEPs. EEGs and LTM, BAERs, VEPs, sleep studies are relatively painless unless you scrub and prep the skin too hard. IOM studies are started and finished under sedation, and therefore not painful, unless your anesthesia person likes to wake the patient up a tad too early. EMG/NCS procedures are a bit more painful, depending on the patient’s sex, age, pain tolerance, attitude, and overall general health. Although an explanation of the procedures is supposed to be done by the referring physician, more often than not, an explanation is never given. So, as I am getting the patient ready for the NCS procedure, I explain to them, and their family if present, what I am going to be doing in the next 30 minutes or so. This involves answering any questions they have and trying to calm any anxiety they have about having the test. If I don’t know the answer to one of their questions, I tell them I will find out the answer as soon as I can and get back with them once the test is over. Once I start the test, I try to talk them through the process of cleaning their skin, putting on the electrodes, performing the actual stimulation, measuring distances, and marking for conduction velocities, etc. After doing this once or twice, most patients learn what the routine is, and any further detailed explanation is usually unnecessary, although there are always patients who need to have further details given to them. At all times, be POSITIVE! Every patient is different and needs to be treated with care, no matter how challenging they are personally. Technical challenges are often less difficult to deal with than personal ones. We, as techs, don’t really know what our patients go through day to day, so trying to be tuned-in to their feelings really helps a lot, no matter how difficult the situation. Once the NCS is completed, I start a simple and preliminary explanation of the EMG study if it is being performed. I try not to go into a lot of detail because the physician performing the EMG will do that. During the study, the doctor will adjust his explanation to his specific study criteria for that patient. Once the study is completed, any unanswered questions will try to be resolved. If the patient asks specific diagnostic questions, it is the doctor who will answer them. If no EMG is performed, I tell the patient and their family that the study will be given to the interpreting physician and that a final report will then go to the patient’s referring physician, even though at times this answer is frustrating to the patient. Remember that you are doing a painful and difficult test to a hurting and anxious patient. A good bedside manner, a sympathetic ear, and a willingness to listen often is the difference between a good and a mediocre study, no matter how technically sound you are.
Please have a wonderful spring and summer. Stay tuned in to ASET for the latest and greatest things in neurodiagnostics.
By Anna-Marie Beck, MOL, R. EEG T.
As I look back at all the times I have attempted to explain what I do to people I have to giggle. I have said things such as:
“Have you seen an ECG? What I do is similar, but I work with the brain, not the heart.” I overheard a physician explain it to a patient this way, and they understood it, so I used it.
“I put ‘buttons’ on a person’s head and watch their brain waves.” I have used this especially with children.
“I teach students how to perform tests on the nervous system, primarily the brain.”
“I work with neurologists.”
If I am speaking to someone who knows a little more about allied health, or health care in general, I give a few more details. However, it is usually simplified for them as many do not know or understand the scope of what we do and who we work with. While this is frustrating to me, especially as an educator and a parent of a child with epilepsy, I must remember not every person in health care is exposed to everything in health care.
Recently some of my students and I were speaking with local high school students about a career in neurodiagnostics. I loved hearing my students tell the high school students that this field is full of possibilities as we don’t know all there is to know about the brain and nervous system and if you want to be a part of something bigger than yourself, neurodiagnostics is a great way to do that. My 5-second blurb regarding our field: “If you have a passion for working with people, learning something new daily, being a detective for physicians, providing answers to the puzzle a physician is trying to figure out; then maybe neurodiagnostics is something you might be interested in. We work closely with physicians and direct patient care staff, but we all work together to ‘solve the puzzle’ for the patient. No two days are the same. I have always enjoyed what I do. The field of neurodiagnostics is ever changing and in that I take comfort. As I near 20 years in the field, I can honestly say that I have not regretted one day of my choice for neurodiagnostics.”
By Mark Ryland, AuD, R. EP T., RPSGT, R.NCS.T., CNCT, FASET
I consider myself to be one of the most fortunate people in the known universe as I have the honor and privilege to be part of an awesome team of dedicated individuals who are responsible for educating and training the next generations of Neurodiagnostic Technologists in our area of Ohio. Our field provides an enormous contribution to patient care, which is so very important. Because the field is changing, growing, and expanding so much, formal education of future technologists is an absolute necessity.
By Bill Coslett, Ph.D., CNIM, BCIA, EEG-C
“……Sleep that knits up the raveled sleeve of care. The death of each day’s life, sore labor’s bath. Balm of hurt minds, great nature’s second course. Chief nourisher in life’s feast…..”
William Shakespeare, one the world’s most prolific dramatist, was a very keen observer of human behavior. Many of his protagonists were afflicted with the pains of life including problems with sleep and vivid dreams. There are those today who say that Shakespeare’s lavish descriptions of character afflictions sets the foundation for many of our present sleep disorders such as night terrors, sleep paralysis, and insomnia. According to Shakespeare, sleep was a “blessing” given to many, but also serves as a curse to those with “restless minds.” Shakespeare understood how sleep effected the immune system as well as our overall general health and wellness. He understood how anxiety/stress and our ability to calm the mind prevents sleep onset and uninterrupted sleep.
Shakespeare’s observation in early 1600 rings true today. It is estimated that insomnia and daytime drowsiness affect 35–40% of the adult population annually and are a significant cause of morbidity and mortality (Ncbi.nlm.nih.gov). The untold impact of insomnia is staggering in terms of loss of productivity, increased risk of chronic health conditions, as well as increased negative impact of our mental health.
Today’s sleep industry is enormous, with billions of dollars in revenues being spent each year to combat the effects of our inability to get and stay sleep. Sleeping medications, such as Lunesta and Ambien, are one of the most widely prescribed prescriptions for general practitioners. Although these medications are safer now than were the benzodiazepines of years ago, there still are concerns about side effects, as well as issues of dependence.
There are so many over-the-counter sleep aids that a comprehensive listing would be impossible for this article. Although many times these medications may help bring about restorative sleep patterns, there remains issues of undesirable and possibly dangerous side effects.
An area that has received a lot of attention in sleep medicine is Neurofeedback. NF is a powerful tool that can help people with difficulties in getting and staying asleep. Studies are beginning to emerge demonstrating that neuro training impacts the sleep regulatory mechanisms in the brain. Many clinicians have documented that the first noticeable change with NF training is an improvement of sleep quality. This seems to hold true whether training is done for ADHD, chronic pain, and/or substance abuse.
The sensory motor rhythm (SMR) is an oscillatory brain wave noted over the sensory motor strip. It is considered by many to an idle rhythm of the brain. For most individuals, this frequency oscillates in the range of 12-15 Hz and is produced with a quieting of the motor cortex. Motion or the thought of movement diminishes the sensory motor rhythm. Another name for this oscillation is the Mu rhythm or what is commonly referred to as a Wicket Rhythm.
In 1963, Barry Sternman, a pioneer in the field of neuroscience, was doing some research involving a Pavlov-like experiment training the brains of cats. Sternman was the first to show that instrumental condition of the SMR was possible. Two very interesting observations were made by Sternman in his research of cats:1) SMR training selectively enhanced spindle activity in subsequent sleep and 2) SMR training produced longer periods of undisturbed sleep.
It is hypothesized that SMR training impacts sleep by increasing sleep spindle density, which results in a normalization of sleep onset. Others suggest that the rationale for SMR training is that increased relaxation combined with inhibition of motor activity should counteract the hyperarousal associated the problems of sleep onset.
Generally, training is placed with one electrode placed on the sensory/motor strip (C3 or C4) and the other electrode placed as a reference over the ear (A1/A2). As a general rule, training from the right side at C4-A2 produces a calming and relaxed affect while left hemisphere (C3-A1) training produces a more energizing and focused affect. The goal of the training is to increase the amplitude of the SMR with auditory and or visual feedback given as a reward when amplitudes exceed a specific threshold. Some NF therapists incorporate a reward for inhibition of Beta along the sensory motor strip. As a general rule, changes in sleep patterns can emerge in as quickly as 6–10 sessions.
Any comprehensive treatment of sleep insomnia should include incorporating positive sleep hygiene practices, general physical exercises, as well as cognitive behavior strategies. It is now being recognized that neurofeedback can be added to help those individuals who have trouble in getting and staying sleep.
By Janna Cheek, R. EEG T., CNIM
Ideas and maneuvers to translate our job and its description to patients by being able to relate to generational phrases or activities to help with communication:
NeuroLinks provides multiple NDT procedures to both in- and outpatients; to the young and old, which at times becomes challenging to explain exactly what we are doing to their head. We commonly answer questions, such as, “Do earlobes have brainwaves in them?” or “Can you read my mind or see what I’m thinking?”
I have explained to the elderly females that it is like the perms their moms use to give them, but this one won’t damage their hair. Another comical explanation I have given elderly men is that I am just needing to confirm that your brain is “clicking on all cylinders” and if not, we have an extra supply of them (cylinders) at a discount price in our backroom.
But I think the most memorable and precious explanation came from a little 6-year-old girl many years ago who told me to please send pretty music to her brain to listen to when she went to sleep. I explained to her that I would do my best, but that this test doesn’t send things into her brain, only records what comes out of her brain. If she likes pretty music, then this test can write down the pretty music she likes to hear on a piece of paper (analog back then) in a language that that the doctor can read.
At the end of her test, I tore off the first couple of pages of recording (BioCal), folded it up, drew a heart on the outside of it with my red china marker, wrote her name on it, and handed it to her on her way out of the exam room letting her know that this was the music her brain wrote down for her doctor to see. That easy little gesture made this little girl so happy and proud. You would have thought I’d given her the moon. She showed it to everyone in the waiting room and her mom called the next week to let me know that she was still sleeping with her “mind’s music waves”.
It takes a lot of creativity and thinking outside the box many times to be able to get your patient to relate, relax, and understand what an EEG is all about and why they need these wires placed on their head.
Acute/Critical Care Neurodiagnostics
By A. Todd Ham, R. EEG T., CLTM, BS
Who doesn’t love a good crossword puzzle? Below you’ll find a downloadable PDF of the “All Things EEG Crossword Puzzle, 2nd Edition.” I encourage you to print it out and quiz yourself on well…all things EEG. I have provided the Horizontal and Vertical clues that you will need as well as a key to check your answers when you’ve completed the puzzle. I hope you enjoy taking a break from your daily routine to exercise those brain muscles.
Crossword Puzzle: All Things EEG, 2nd Edition
DOWNLOAD PUZZLE: Crossword Puzzle Spring 2018
4. Seizures are provoked by pouring hot water over head. Although not as common,seizures can also occur while patient is showering or bathing.
7. Greater than 50 % of adults have an asymmetric PDR. Is it right or wrong that the left side is usually higher amplitude?
9. In the elderly it’s normal to see some mild, infrequent slowing in the temporal regions. Right or wrong that it’s mostly found in left hemisphere?
11. The photic flash frequency which is often most prominent is near the frequency of the patient’s?
12. The polarity of spikes and sharp waves is usually what when recorded from the scalp?
15. Caused by toxic/metabolic encephalopathies, subcortical lesions, and increased ICP.
17. Medication type which during sleep often results in less vertex waves and K complexes, but more pronounced sleep spindles?
19. Which temporal lobe epilepsy type is commonly associated with temporal onset of rhythmic theta or delta?
21. Most commonly-identified etiology of unprovoked seizures and symptomatic epilepsy in older adults.
23. The photic light should be placed approximately ____ cm from the patient’s face.
1. Slow flicker photic stimulation induces pronounced occipital spikes in patients with?
2. Type of Childhood Occipital Epilepsy. Visual symptoms, migraines with nausea and vomiting.
3. First, focal onset. Then, generalized discharge. “Secondary _______ ________”.
5. NCSE which lasts for > ___ is associated with significant disability; longer durations are associated with death.
6. Focal seizures presenting as diffuse, anteriorly- maximal voltage attenuation as ictal discharges are obscured by EMG & intense movement.
8. The photic frequency (Hz) most likely to elicit paroxysmal response.
10. With respect to epileptiform spike-wave complexes, the after-going slow waves are the result of?
13. Which temporal lobe epilepsy type is commonly associated with temporal onset of beta activity?
14. Front-line treatment choice for eclampsia; effectiveness likely due to its directly affecting (via the endothelium) the underlying seizure cause.
16. Start very low and go very slow’ to avoid life- threatening skin rashes. Not effective for myoclonic jerk seizures.
18. The PDR is often faster during the first few seconds of eye closure.
20. SREDA is a normal finding expected in patients over ____ years old.
22. With respect to epileptiform spike-wave complexes, spikes are the result of?
References for the crossword puzzle:
- The PDR is often faster during the first few seconds of eye closure. Squeak p. 103 Yamada Practical Guide for Clinical Neurophysiologic Testing – EEG 2010.
- Medication which during sleep often results in less vertex waves and k complexes but more pronounced sleep spindles? Benzodiazepine p. 141 Yamada Practical Guide for Clinical Neurophysiologic Testing – EEG 2010.
- With respect to epileptiform spike-wave complexes, spikes are the result of EPSP (acronym please). P. 152 Yamada Practical Guide for Clinical Neurophysiologic Testing – EEG 2010.
- With respect to epileptiform spike-wave complexes, the after-going slow waves are the result of IPSP (acronym please). P. 152 Yamada Practical Guide for Clinical Neurophysiologic Testing – EEG 2010.
- The photic flash frequency which is often most prominent is near the frequency of the patient’s? PDR p. 158 Yamada Practical Guide for Clinical Neurophysiologic Testing – EEG 2010.
- Which temporal lobe epilepsy type is commonly associated with temporal onset of beta activity? Neocortical p. 178 Yamada Practical Guide for Clinical Neurophysiologic Testing – EEG 2010.
- Which temporal lobe epilepsy type is commonly associated with temporal onset of rhythmic theta or delta? Mesial p. 178 Yamada Practical Guide for Clinical Neurophysiologic Testing – EEG 2010.
- Seizures often present as diffuse, anteriorly-maximal voltage attenuation as ictal discharges are hidden by intense movement, EMG artifact. Frontal lobe p. 183 Yamada Practical Guide for Clinical Neurophysiologic Testing – EEG 2010.
- Slow flicker photic stimulation induces pronounced occipital spikes in patients with? Batten’s disease p. 239 Yamada Practical Guide for Clinical Neurophysiologic Testing – EEG 2010.
- NCSE which lasts for > ___ is associated with significant disability; longer durations are associated with death. Ten hours p. 300 Handbook of ICU EEG Monitoring by Laroche 2013.
- NCSE = > __ min. of seizures without convulsions (spell out). Thirty p. 171 Handbook of ICU EEG Monitoring by Laroche 2013
- Front-line choice for treating eclampsia; effectiveness likely due to its directly affecting (via endothelium) underlying cause of the seizures. Magnesium p. 282 Handbook of ICU Monitoring by Laroche 2013
- In addition to myogenic activity seen in bitemporal regions during eating, slow wave artifact is expected due to actions of this during swallowing. Tongue p.18 Handbook of EEG Interpretation by Tatum (2008)
- In elderly patients its normal to have some slowing in temporal regions. The slowing is most often within left hemi. Right or Wrong? Right. P. 34 Handbook of EEG Interpretation by Tatum (2008)
- The photic light should be placed no further than ____ cm away from the patient (spell out please). Thirty. p. 41 Handbook of EEG Interpretation by Tatum (2008)
- SREDA is an expected finding in some patients who are over _____ years old (spell out please). Fifty p.49 Handbook of EEG Interpretation by Tatum (2008)
- Caused by toxic/metabolic encephalopathies, subcortical lesions, and increased ICP. FIRDA p. 57 Handbook of EEG Interpretation by Tatum (2008)
- Spikes and sharp waves have a polarity that is usually at the surface of the scalp recording. Negative p. 75 Handbook of EEG Interpretation by Tatum (2008)
- First, focal onset. Then, generalized discharge. Secondary Bilateral Synchrony. P. 87 Handbook of EEG Interpretation by Tatum (2008)
- The photic frequency (Hz) most likely to elicit paroxysmal response (spell out please). Fifteen. P. 88 Handbook of EEG Interpretation by Tatum (2008)
- > 50% of adults have asymmetric PDR. Typically, the left side is associated with higher amplitude. Right or Wrong? Wrong. P. 110 Yamada Practical Guide for Clinical Neurophysiologic Testing – EEG 2010
- Childhood Epilepsy with Occipital Paroxysms – visual symptoms, migraine with nausea and vomiting. Gastaut. P. 172 Yamada Practical Guide for Clinical Neurophysiologic Testing – EEG 2010
- Most often seizures provoked by pouring hot water over head. Seizures can also occur while patient is showering or bathing. Hot water epilepsy p.526 A Clinical Guide to Epileptic Syndromes and their Treatment – Second edition 2010. Panayiotopoulos
- “Start very low and go very slow” to avoid life-threatening skin rashes. Not effective for myoclonic jerk seizures. Lamictal. P. 583 A Clinical Guide to Epileptic Syndromes and their Treatment – Second edition 2010. Panayiotopoulos
- Most commonly identified etiology of unprovoked seizures and symptomatic epilepsy in older adults. Ischemic Stroke. P 43 Handbook of ICU EEG Monitoring by Laroche 2013.
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